DISEASES OF THE EYE 



SWANZY 



A HANDBOOK 



DISEASES OF THE EYE 



AND THEIR 



TREATMENT 



BY 

HENRY R. SWANZY, A.M., M.B., F.R.C.S.I. 

SURGEON TO THE ROYAL VICTORIA EYE AND EAR HOSPITAL, AND OPHTHALMIC SURGEON 

TO THE ADELAIDE HOSPITAL, DUBLIN, EX-PRESIDENT OF THE OPHTHALMO- 

LOGICAL SOCIETY OF THE UNITED KINGDOM 



EIGHTH EDITION REVISED 
IVITH i68 ILLUSTRATIONS 

AND ZEPHYR CARD OF HOLMGREN'S TESTS 



PHILADELPHIA 
P. BLAKISTON'S SON & CO. 

IOI2 WALNUT STREET 
1903 



THt LIBRARY OF 
CONGRESS, 

T»vo Copies Received 

AUG 25 1903 

Copyiiglit £.ntry 
(k^k%% (^ XXc No 
COPY B, 






Copyright, 1903, by P. Blakiston's Son & Co. 



I DEDICATE THIS BOOK 

TO 

THEODOR LEBER, 

PROFESSOR AT THE UNIVERSITY OF HEIDELBERG 

AS A MARK OF 

MY ADMIRATION- FOR HIS EMINENT SERVICES 

TO OPHTHALMOLOGY, 

AND OF 
MY SINCERE REGARD. 



TO THE STUDENT. 

You should read carefully Chapters L, 11. , and III., omitting at 
first the small print, either before or immediately on joining the 
Ophthalmic Hospital or Department. 

H. R. S. 



PREFACE TO THE EIGHTH EDITION. 

In the preparation of this Edition the book has been again re- 
vised throughout. Moreover, some fresh matter has been intro- 
duced, and some obsolete matter omitted, in order to bring the 
work up to date, without materially increasing its size. The fol- 
lowing are some of the additions : — In Chapter IV., A Description 
of Conjunctivitis Petrificans; in Chapter VI., A Description of 
Grating Keratitis, Guttate Keratitis, Keratitis Aspergillina, Re- 
current Abrasion of the Cornea, and of Injuries of the Cornea 
caused by blows and Burns ; in Chapter VII., A More Detailed 
Account of Herpes Zoster Ophthalmicus, A Description of Lym- 
phangiodes of the Eyelids, and of Pfliiger's Method of Tarsor- 
rhaphy; in Chapter VIII., A More Detailed Account of Kuhnt's 
Method of Extirpation of the Lacrimal Sac ; in Chapter X., in 
view of the vast importance of the subject, A More Detailed Ac- 
count of Sympathetic Ophthalmitis ; in Chapter XIV., A More 
Detailed Account of the Use of the Magnet for Foreign Bodies in 
the Eye ; in Chapter XVL, A More Detailed Account of Tumors 
of the Optic Nerve; in Chapter XVII. , A Description of the Eye 
Symptoms attendant upon Myasthenia Gravis; in Chapter 
XVIIL, A Description of Mr. P. W. Maxwell's Operation for 
Shrunken Socket, and of Professor Kronlein's Temporary Resec- 
tion of the Outer Wall of the Orbit for Orbital Tumors, etc. ; in 
Chapter XIX., A Description of Amaurotic Family Idiocy. 

I am indebted to Dr. Kathleen Lynn for the great care she has 
given to the preparation of the Index. 

23 Merrion Square, 
June, 1903. 



PREFACE TO THE FOURTH EDITION. 

The Third Edition of this book was pubhshed in October, 1890, 
and I am gratified that the work continues to find favor, not only 
with students, for whom it is mainly intended, but also with prac- 
titioners. 

The book has now again been revised throughout, and brought 
up toi date. 

In an Appendix, Holmgren's Method for Testing the Color 
Sense has been described in greater detail than before. 

Some new illustrations have been added. 

The great difficulty of an author in the preparation of a book 
like this consists in " Saying not all he might, but all he ought." 
It is his duty to give a succinct and practical account of his sub- 
ject in its most modern aspect, without weighting his pages with 
excessive detail and prolonged discussion. This has been my 
aim. For deeper and wider information, larger handbooks and 
original monographs must be consulted. 

23 Mf.rrton Square, 
October, 1892. 



CONTENTS. 

CHAPTER I. 

PAGE 

Numbering of Trial-Lenses and Spectacle Glasses — Normal Refrac- 
tion and Accommodation — The Meter Angle — The Angle 
Gamma — The Sense of Sight (Light-Sense, Color-Sense, Form- 
Sense) — The Field of Vision . . . . = . . .17 



CHAPTER II. 

ABNORMAL REFRACTION AND ACCOMMODATION. 

Hypermetropia — Correction of H. — Amplitude of Accommodation in 
H. — Angle Gamma in H. — Cramp of Ciliary Muscle in H. — Ac- 
commodative Asthenopia in H. — Internal Strabismus in H. — 
The Prescribing of Spectacles in H 2>^ 

Myopia — Determination of Degree of M.— Amplitude of Accommoda- 
tion in M. — Angle Gamma in M. — Complications of Progressive 
M. — Functional Anomalies Attendant upon M. — Management of 
M. — The Prescribing of Spectacles in M. — Operative Cure of M. 42 

Astigmatism — Symptoms of As. — Estimation of Degree of, and Cor- 
rection of As. — The Astigmometer — Lental As. — Irregular As. . 52 

Anisometropia 64 

Anomalies of Accommodation — Presbyopia — Paralysis of Accommo- 
dation — Cramp of Accommodation 64 



CHAPTER HI. 

THE OPHTHALMOSCOPE. 

Why Necessary — Helmholtz's Ophthalmoscope — Modern Ophthalmo- 
scope — Direct Method — Indirect Method 70 

Estimation of the Refraction by Aid of the Ophthalmoscope — Direct 

Method — Retinoscopy 76 

Focal Illumination 87 

The Normal Fundus Oculi as Seen with the Ophthalmoscope — The 
Optic Papilla, or Optic Disc— The Retina— The Macula Lutea— 
The General Fundus Oculi — The Retinal Vessels . . . .88 



lo CONTENTS. 

CHAPTER IV. 

DISEASES OF THE CONJUNCTIVA. 

PAGE 

Hyperemia — Conjunctivitis — Catarrhal Conjunctivitis — Acute Blen- 
norrhea of the Conjunctiva, or Purulent Ophthalmia — Follicular 
Conjunctivitis — Spring Catarrh — Hay Fever — Trachoma, Granu- 
lar Conjunctivitis, or Granular Ophthalmia — Acute Trachoma, or 
Acute Granular Ophthalmia — Chronic Trachoma, or Chronic 
Granular Ophthalmia — Lymphoma of the Conjunctiva — Croupous 
Conjunctivitis — Diphtheritic Conjunctivitis — Conjunctival Com- 
plications of Smallpox — Amyloid Degeneration — Tubercular Dis- 
ease of the Conjunctiva — Lupus — Pemphigus — Xerosis, or 
Xerophthalmos — Pterygium — Pinguecula — Subconjunctival Ec- 
chymosis — Nevus — Polypus — Dermoid Tumors — Lipoma — Syphil- 
itic Disease of the Conjunctiva — Papilloma, or Papillary Fibroma 
— Epithelioma — Sarcoma — Simple Cysts — Subconjunctival Cysti- 
cercus — Lithiasis — Conjunctivitis Petrificans — Uric Acid De- 
posits — Injuries of the Conjunctiva 93 

CHAPTER V. 

PHLYCTENULAR, OR STRUMOUS, CONJUNCTIVITIS AND KERATITIS. 

Solitary, or Simple, Phlyctenula of the Conjunctiva — Multiple, or 
Miliary, Phlyctenula of the Conjunctiva — Modes of Secondary 
Corneal Affection — Primary Phlyctenular Keratitis — Different 
Forms of Same — Symptoms of Phlyctenular Keratitis — Causes of 
Phlyctenular Ophthalmia — Treatment 133 

CHAPTER VI. 

DISEASES OF THE CORNEA. 

Inflammations of the Cornea — (a) Ulcerative Inflammations of the 
Cornea — Simple Ulcer — Deep Ulcer — Serpiginous Ulcer — Rodent 
Ulcer — Marginal Ring Ulcer — Absorption Ulcer — Neuro-Paralytic 
Keratitis — Infantile Ulceration of the Cornea with Xerosis of the 
Conjunctiva — Herpes' — Filamentary Keratitis — Bullous Keratitis 
— Dendriform Keratitis — Keratitis Aspergillina .... 140 
(b) Non-Ulcerative Inflammations of the Cornea — Abscess — Dif- 
fuse Interstitial, or Parenchymatous, Keratitis — Keratitis Pro- 
funda— Grating-like Keratitis— Guttate Keratitis— Keratitis Punc- 
tata — Sclerotizing Opacity — Riband-like Keratitis . . . 161 

Ectasies of the Cornea — Staphyloma Cornese (Evisceration and Mules' 

Operation) — Conical Cornea, or Keratoconus .... i6g 

Tumors of the Cornea .... 177 



CONTENTS. II 



Injuries of the Cornea — Foreign Bodies — Losses of Substance — Re- 
current Abrasion, or Disjunction — Blows — Burns — Perforating 
Injuries 177 

Opacities of the Cornea — Nebula, ^lacula, Leukoma — Arcus Senilis . 183 

CHAPTER VII. 

DISEASES OF THE EYELIDS. 

Eczema — Herpes Zoster Ophihalmicus — Primary Syphilitic Sores — 
Secondary Syphilitic Sores — Tertiary Syphilitic Affection — Vac- 
cine Vesicles — Rodent Ulcer — Marginal Blepharitis (Ophthalmia 
Tarsi) — Phtheiriasis Ciliorum — Hordeolum (Stye) — Chalazion 
(Meibomian Cyst, Tarsal Tumor) — Milium — Molluscum — Nevus 
— Xanthelasma — Chromidrosis — Epithelioma, Sarcoma, Adenoma 
and Lupus — Solid Edema, or Elephantiasis Lymphangioides — 
Clonic Cramp of the Orbicularis JMuscle — Blepharospasm — Ptosis 
— Operations for its Cure — Lagophthalmos — Symblepharon — Ble- 
pharophimosis — Canthoplastic Operation — Distichiasis and Tri- 
chiasis — Operations for their Cure — Entropium — Operations for its 
Cure — Spastic Entropium — Senile Entropium — Operations for its 
Cure — Ectropium — Operations for its Cure — Ankyloblepharon — 
The Restoration of an Eyelid — Injuries — Ecchymosis — Epicanthus 
— Congenital Coloboma 187 

CHAPTER VIII. 

DISEASES OF THE LACRIMAL APPARATUS. 

Malposition of the Punctum Lacrimale — Stenosis and Occlusion of the 
Punctum Lacrimale — Obstruction of the Canaliculus — Stricture 
of the Nasal Duct — Blennorrhea of the Lacrimal Sac — Oblitera- 
tion and Extirpation of the Lacrimal Sac — Acute Dacryocystitis — 
Dacryoadenitis — Hypertrophy of the Lacrimal Gland . . . 233 

CHAPTER IX. 

DISEASES OF THE SCLEROTIC. 

Inflammations of the Sclerotic — Periodic Transient Episcleritis, or 
Hot Eye — Episcleritis — Deep Scleritis — Injuries of the Sclerotic — 
Tumors of the Sclerotic — Pigment Spots 244 

CHAPTER X. 

DISEASES OF THE UVEAL TRACT. 

Iritis — Symptoms — Syphilitic — Rheumatic — Gonorrheal — Causes 

— Prognosis — Treatment . . 250 



12 CONTENTS. 



Cyclitis 259 

Chorioiditis — Disseminated — Syphilitic — Central Senile Guttate — Cen- 
tral — Purulent 261 

Sympathetic Ophthalmitis, and Sympathetic Irritation — Introductory 
— Sympathetic Irritation — Sympathetic Ophthalmitis — Diagnosis 
— Prognosis — Treatment — Prophylaxis — Therapeutic and Optical 
Operations used in Sympathetic Ophthalmitis — Pathogenesis . 265 

Injuries of the Iris — Punctured Wounds — Foreign Bodies — Irido- 
dialysis — Retrofleijcion — Rupture — Dehiscence — Traumatic My- 
driasis 284 

Injuries of the Ciliary Body — Punctured Wounds — Foreign Bodies . 287 

Injuries of the Chorioid — Foreign Bodies — Incised Wounds — Rup- 
ture — Extravasation of Blood 288 

New Growths of the Iris — Cysts — Granuloma — Tubercle — Sarcoma — 

Ophthalmia Nodosa 289 

New Growths of the Ciliary Body — Sarcoma — Myosarcoma — Car- 
cinoma 292 

New Growths of the Chorioid — Sarcoma — Carcinoma — Tubercle — 

Sarcoma Carcinomatosum — Myosarcoma — Osteosarcoma . . 292 

Other Diseases of the Chorioid — Posterior Staphyloma — Detachment 

— Central Senile Areolar Atrophy . 297 

Malformations of the Iris . . . . . . . . , 297 

Malformations of the Chorioid 298 

Operations on the Iris 300 

CHAPTER XL 

MOTIONS OF TflE PUPIL IN HEALTH AND DISEASE. 

The Size of the Pupil in Health — Contraction of the Pupil — Dilata- 
tion of the Pupil 303 

The Action of the Mydriatics and Myotics on the Pupil . . . 309 
The Size of the Pupil in Disease — Myosis — Mydriasis . . . 309 

Tabular Arrangement of Mydriatics, Myotics, and Anesthetics . 316 

CHAPTER XII. 

GLAUCOMA. 

Primary Glaucoma — Chronic, or Non-Inflammatory, Glaucoma — 
Acute, or Inflammatory, Glaucoma — Glaucoma Fulminans — Sub- 
acute Glaucoma — Etiology — Pathology — Treatment . . . 320 

Congenital Hydrophthalmos 340 

CHAPTER XIII. 

DISEASES OF THE CRYSTALLINE LENS. 

Complete Cataracts — Senile Cataract — Progress, Pathogenesis, and 

Etiology — Treatment 342 



CONTENTS. 13 



Complete Cataract of Young People— Diabetic Cataract — Complete 

Congenital Cataract — Black Cataract 349 

Partial Cataracts — Central Lental Cataract — Zonular, or Lamellar, 
Cataract — Anterior Polar, or Pyramidal, Cataract — Fusiform, or 
Spindle-Shaped, Cataract 35o 

Secondary Cataract — Posterior Polar Cataract — Total Secondary 

Cataract 352 

Capsular Cataract 353 

Traumatic Cataract 353 

Operations for Cataract — Extraction of Cataract — Linear Extraction 
The Modified Peripheral Linear Extraction — The Three Milli- 
meter Flap Operation — Cataract Extraction without Iredectomy . 355 

Discission, or Dilaceration — Suction Operation — Secondary Cataract 

and its Operation — Capsulotomy — Iridotomy 37^ 

Dislocation of the Crystalline Lens — Lenticonus — Aphakia . . . 3^1 



CHAPTER XIV. 

DISEASES OF THE VITREOUS HUMOR. 

Purulent Inflammation — Other Inflammatory Affections — Opacities — 
Muscle Volitantes — Fluidity (Synchysis) — Synchysis Scintillans — 
Foreign Bodies in the Vitreous Humor and Interior of the Eye in 
General — Use of Rontgen Rays in Detecting Foreign Bodies — 
The Sideroscope — Removal of Foreign Bodies — The Magnet — 
Cysticercus — Blood- Vessels — Persistent Hyaloid Artery — Detach- 
ment ........ 384 

CHAPTER XV. 

DISEASES OF THE RETINA. 

Alterations in Vascularity — Hyperemia — Anemia 400 

Retinitis — Syphilitic — Hemorrhagic — Albuminuric — Diabetic — Leu- 
kemic — Punctata Albescens — Development of Connective Tissue, 
or Retinitis Proliferans — Retinitis Circinata — Purulent Retinitis . 401 

Atrophy of the Retina — Retinitis Pigmentosa — Gyrate Atrophy of the 

Retina and Chorioid 407 

Diseases of the Retinal Vessels — Apoplexy of the Retina — Embolism 
of the Central Artery — Thrombosis of the Central Artery — 
Thrombosis of the Central Vein — Aneurysm of the Central Artery 
—Sclerosis of the Retinal Vessels (Perivasculitis)— Quinin 
Amaurosis 4^9 

Injury of the Retina by Strong Light — Sunlight — Snow-Blindness — 

Effect of Electric Light on the Eyes 4I5 

Tumor of the Retina — Glioma 416 

Parasitic Disease of the Retina— Cysticercus . . , . • 4^7 



14 CONTENTS. 



Detachment of the Retina 4^^ 

Traumatic Affections of the Retina — Traumatic Anesthesia — Com- 
motio Retinae, or Traumatic Edema of the Retina .... 422 

CHAPTER XVI. 

DISEASES OF THE OPTIC NERVE. 

Optic Neuritis (Papillitis), due to: Cerebral Tumors — Tubercular 
Meningitis — Hydrocephalus — Tumors of the Orbit — Inflammatory- 
Processes in the Orbit — Exposure to Cold — Suppression of Men- 
struation — Chlorosis — Syphilis — Rheumatism — Lead Poisoning — 
Peripheral Neuritis — Multiple Sclerosis — Tabes Dorsalis — Acute 
Myelitis — and to Hereditary and Congenital Predisposition . . 424 

Toxic Central Amblyopia, or Central Scotoma — Retrobulbar Neuritis 
— Optic Neuritis, Associated with Persistent Dropping of Watery 
Fluid from the Nostril 429 

Atrophy of the Optic Nerve, due to : Optic Neuritis — Pressure — 
Embolism of the Central Artery of the Retina — Syphilitic Reti- 
nitis, Retinitis Pigmentosa, Choriodo-Retinitis, and to Disease of 
the Spinal Cord (Spinal Amaurosis) — Optic Atrophy as a purely 
Local Disease 433 

Tumors of the Optic Nerve — Hyaline, or Colloid, Outgrowths — In- 
juries of the Optic Nerve 436 

Amblyopia due to Hemorrhage from the Stomach, Bowels, or Uterus 

— Glycosuric Amblyopia 437 

CHAPTER XVII. 

THE MOTIONS OF THE EYEBALLS, AND THEIR DERANGEMENTS. 

Actions of the Orbital Muscles — Inclination of the Vertical Meridian 
in the Several Principal Positions — Muscles called into Action 
in the Several Principal Positions — The Field of Fixation — 
Strabismus 441 

Paralyses of the Orbital Muscles — General Symptoms — Paralysis of 
the External Rectus — Paralysis of the Superior Oblique — Paral- 
sis of the Internal Rectus, Superior Rectus, Inferior Oblique, and 
Levator Palpebrse — Ophthalmoplegic Migraine — Ophthalmoplegia 
Externa, or Nuclear Paralysis — Fascicular Paralysis — Myasthenia 
Gravis — Cerebral Paralysis of Orbital Muscles — The Localizing 
Value of Paralysis of Orbital Muscles in Cerebral Disease . 447 

Convergent Concomitant Strabismus — Causes — Single Vision in — 
Amblyopia of Squinting Eye — Clinical Varieties of — Measure- 
ment of — Mobility of Eye in — Treatment — Orthoptic Treatment 
— Operative Treatment — Tenotomy — Advancement of External 
Rectus — Dangers of the Strabismus Operation — Treatment Sub- 
sequent to Operation 471 



CONTENTS. 15 



Insufficiency of the Internal Recti, and Divergent Concomitant Stra- 
bismus — Muscular Asthenopia — Treatment — Operative Treatment 494 
Nystagmus 499 



CHAPTER XVIII. 

DISEASES OF THE ORBIT. 

Orbital Cellulitis — Periostitis of the Orbit — Caries of the Orbit — 
Injuries of the Orbit — Orbital Tumors — Implication of Neighbor- 
ing Cavities — Pulsating Exophthalmos — Tumors of the Lacrimal 
Gland — Hernia Cerebri — Exophthalmic Goiter — Enophthalmos . 501 



CHAPTER XIX. 
PART I. 

OCULAR DISEASES AND SYMPTOMS LIABLE TO ACCOMPANY FOCAL DISEASES 

OF THE BRAIN. 

Hemianopsia — Arrangement of the Cortical Visual Centers, their Re- 
lations to the Retina, and the Course of the Optic Fibers between 
these Two Points — Localization of the Lesion in Hemianopsia — 
Alexia, or Word-BHndness — Visual Aphasia — Dyslexia — Amnestic 
Coior-Blindness — Visual Hallucinations — ]\Iind-Bhndness, or 
Optic Amnesia 522 

PART II. 

OCULAR DISEASES AND SYMPTOMS LIABLE TO ACCOMPANY DIFFUSE 
ORGANIC DISEASES OF THE BRAIN. 

Disseminated Sclerosis of the Brain and Spinal Cord — Diffuse Scle- 
rosis of the Brain — General Paralysis of the Insane — Amaurotic 
Family Idiocy — Meningitis — Traumatic Meningitis — Hydrocepha- 
lus — Infantile Paralysis — Paralysis Agitans — Encephalopathia 
Saturnia — Epilepsy — Chorea 53^ 

PART III. 

OCULAR DISEASES AND SYMPTOMS LIABLE TO ACCOMPANY DISEASES AND 
INJURIES OF THE SPINAL CORD. 

Tabes Dorsalis — Hereditary Ataxy — Myelitis — Syringomyelia, and 
Morvan's Disease — Myotonia Congenita — Acute Ascending Paral- 
ysis — Injuries of the Spinal Cord ....... 543 



i6 CONTENTS. 

PART IV. 

NERVOUS AMBLYOPIA, OR NERVOUS ASTHENOPIA. 

PAGE 

Nervous Amblyopia in Neurasthenia — Nervous Amblyopia in Hys- 
teria — Nervous Amblyopia in Traumatic Neurosis . . . 547 

PART V. 

VARIOUS FORMS OF AMBLYOPIA. 

Transitory Hemianopsia, or Scintillating Scotoma — Congenital Am- 
blyopia — Reflex Amblyopia — Night-Blindness — Uremic Amblyopia 
Pretended Amaurosis — Erythropsia . . . » . . 552 

APPENDIX I. 
Holmgren's Method for Testing the Color-Sense . . . . . 559 

APPENDIX II. 

Regulations as to Defects of Vision which Disqualify Candidates for 
Admission into the Civil, Naval, and Military Government Serv- 
ices, the Royal Irish Constabulary, and the Mercantile Marine . 56? 

Index. ............. 567 



DISEASES OF THE EYE. 



CHAPTER I. 

THE NUMBERING OF TRIAL-LENSES. 

The lenses in trial cases and in spectacles are numbered ac- 
cording to the metrical system. 

The lens of one meter (39 1-2 inches) focal length is called 
the Dioptric Unit, or the Dioptry (i D), of the metrical system. 
2 D, 3 D, 4 D, etc., indicate the number of meter lenses, or 
dioptrics, contained in each of these lenses. 2 D is therefore 
twice as powerful a lens (its focal length only half as long) as 
I D. 

Convex lenses are indicated by the + sign placed before their 
number, thus, -]- 5 D; and concave lenses by the — sign, thus, 
-5D. 

If it be required to ascertain the focal length of a given 
lens, 100 (i meter = 100 cm.) is to be divided by the dioptric 
number of the lens, and the answer will give the focal length in 
centimeters. For example, the focal length of 10 D is W^ = 
10 cm. 

If the focal length of the lens be known, and it be desired to 
ascertain its dioptric number, we find it by dividing 100 cm. 
by the focal length. For example, if the focal length be 33 cm., 
then VV = 3 D- 

THE POWERS OF NORMAL REFRACTION AND 
ACCOMMODATION OF THE EYE. 

The eye is a dark chamber with a series of convex refracting 
surfaces — namely, the cornea, and the anterior and posterior sur- 
faces of the crystalline lens ; and certain intraocular or dioptric 
media — namely, the aqueous humor, the substance of the crystal- 
line lens, and the vitreous humor. By aid of this apparatus, which 



i8 DISEASES OF THE EYE. 

is called the dioptric system of the eye, distinct inverted images 
of external objects are formed on the retina. 

The refracting media are centered on the optical axis {O A, 
Fig. i) an imaginary line which, passing through the optical 
center (A^) of the eye, meets the retina at a point {A) slightly 
to the inner side of the macula lutea (M). 

In treating of the eye we have to consider two sets of visual 
objects — viz., distant objects and near objects. Distant objects 




Fig. I {right eye). 

are those at 6 meters and more from the eye ; near objects are 
those closer to the eye than 6 meters. For practical purposes the 
rays which pass through the pupil, coming from any given point 
of a distant object, are as good as parallel, their divergence being 
so very slight when they reach the eye, and we regard them as 
being parallel. 

Refraction. 

By the Refraction of the Eye is meant the faculty it has when 
at rest {i. e., without an effort of accommodation) of altering 
the direction of rays of light which pass into it, making parallel 
rays convergent, and divergent rays less divergent. 

In Normal Refraction, or Emmetropia (e'jajuerpov, the 
standard; ojip, the eye), as it is termed, parallel rays (see Fig. 2, 
in which the object from which the rays come is supposed to be 
6 meters or more from the eye) in passing through the dioptric 
media are given such a convergence that they are brought to a 
focus on the layer of rods and cones of the retina, and form on it 
a distinct inverted image of the point or object from which they 
come. In other words, the retina is placed at the principal focus 
of the dioptric system of the normal eye, which is thus adapted 
for parallel rays, and its far point {vide infra) is at infinity. 



ACCOMMODATION. 



19 



Accommodation. 

The eye can see near objects distinctly as well as distant ob- 
jects, although the rays from any given point (a, Fig. 3) of a 
near object reach the eye with a divergence so considerable that 
they could not be brought to a focus on the retina by the unaided 
refraction, but would converge towards a point (their conjugate 




Fig. 2. 



focus a') behind the retina, and would not form a distinct image 
on the latter, but merely a blurred image or circle of diffusion 
(at & c). It is obvious, therefore, that an increase of refracting 
power in the eye is necessary, in order that near objects may be 




Fig. 3. 



distinctly seen. It is this increase in the refracting power for 
the purpose of near vision which is called Accommodation. 

The Mechanism of Accommodation is as follows : The 
ciliary muscle (m, Fig. 4) contracts, thus drawing forward the 
chorioid and the ciliary processes, and relaxing the zonuh of 



20 DISEASES OF THE EYE. 

Zinn (2), which is attached to the latter. The lens (/), which 
was flattened by the tension of the zonula, is now free to assume 
a more spherical shape, in response to its own elasticity. The 
posterior surface of the lens scarcely alters in shape, being fixed 
in the patellary fossa; but the anterior surface becomes more 
convex, thus increasing its refracting power. Associated with 
the act of accommodation is a contraction of the pupil. The 
acompanying figure (Fig. 4) represents the changes which take 
place in accommodation, the dotted lines indicating the latter 
state. 

Tscherning^ has shown that the increased curvature of the an- 
terior surface of the lens occurs mainly in the center of that sur- 
face — in other words, that in accommodation the anterior surface 
becomes somewhat conical, and not merely more spherical. He 




Fig. 4. — c, cornea ; a, anterior chamber ; /, lens ; v, vitreous humor ; i, iris ; 
2, zonula of Zinn; m, ciliary muscle. 

holds that this is due to a tightening, and not to a relaxation of 
the zonula. This theory has been vigorously combated by other 
observers, and its true value remains to be determined. 

The Far Point and the Near Point.— It is possible for the 
eye to see objects accurately at every distance from its Far Point 
— i e., its most distant point of distinct vision (Punctum Re- 
motum, — R.), up to a point only a few centimeters from the eye, 
called the Near Point (Punctum Proximum, — P.). We can 
find the latter by directing the patient to look at a page printed 
in small type, and by bringing it slowly closer and closer to his 



ACCOMMODATION. 21 

eye, until a point is reached where he cannot distinguish the 
words and letters, which become blurred. A point very slightly 
more removed from the eye than this, where he can read dis- 
tinctly, is the near point. Between the near point and the eye 
vision is indistinct, because no effort of the ciliary muscle can 
produce the amount of convexity of the lens required for so 
short a distance. 

The Amplitude of Accommodation. — This is the amount of 
accommodative effort of which the eye is capable — i. e., the effort 
it makes in order to adapt itself from its Far Point (R.) up to 
its Near Point (P.). The amplitude of accommodation {a), 
therefore, is equal to the difference between the refracting power 
of the eye when at rest (r), and when its accommodation is 
exerted to the utmost (/>), as expressed by the formula a = 




Fig. 5. 

p — r. It may be represented by that convex lens placed close 
in front of the eye, which would take the place of the increased 
convexity of the lens, or, in other words, which would give to 
rays coming from the nearest point of distinct vision a direction 
as if they came from the far point. The number of this lens ex- 
presses the amplitude of accommodation in a given eye. 

For example: if, in an emmetropic eye {E, Fig. 5) the near 
point be situated at 20 cm., then a convex lens (L) of 20 cm. 
focal length placed close to the eye (between that point and the 
eye) would give to rays coming from the near point a direction 
{i. e., would make them parallel) as though they came from a 
distant object, and this normally refracting eye would then be 
enabled by aid of its refraction alone to bring these rays to a 
focus on the retina. Making use of the above equation, we find in 
this case — since a focal length of 20 cm. represents a lens of 



22 DISEASES OF THE EYE. 

5 D — that a = 5 — r, but R. being situated at infinity we desig- 
nate it by the sign 00 ; hence, r =z — - = — = o ; therefore a 

= 5 — 0=5 D.* 

The amount of ampHtude of accommodation (i. e., the num- 
ber of the lens which would represent it) is the same in every 
kind of refraction, according to the age of the individual, but in 
emmetropia alone is a = p as above, because in it alone is r = o. 

Under the head of " Anomalies of Accommodation," chap, ii., 
will be found Professor Bonders' diagram representing the ampli- 
tude of accommodation at different ages. 

Connection betv^een Accommodation and Convergence 
(Relative Accommodation). — With every degree of con- 
vergence of the visual lines a certain effort of accommodation is 
associated. Thus, if the object be situated 2 meters from the eye 
the visual lines converge to that point, and a certain effort of ac- 
commodation is made. But this connection between accommo- 
dation and convergence is somewhat elastic, for the accommodative 
effort may be increased or decreased, while the object is kept dis- 
tinctly in view, and the same convergence maintained. That it 
may be increased is shown by the experiment of placing a weak 
concave glass before the eye, when it will be found that the ob- 
ject is still distinctly seen ; and if a weak convex glass be then 
held before the eye the object will also be clearly seen, showing 
that the accommodative effort may be lessened without affecting 
vision or convergence. This amplitude of accommodation for a 
given point of convergence of the visual lines, found by the 
strongest concave and strongest convex glasses with which the 
object can still be distinctly seen, is called the Relative Amplitude 
of Accommodation. That part of it which is already in use, and 

* It must be observed that R represents the distance of the Far Point 
from the eye, while r represents the refractive power which is added to 
the eye by accommodation or by a lens in order to adapt it for the distance 
R. Hence it is evident that r = ^, because the strength, or refractive 
power, of a lens is inversely as its focal length — e. g., a lens of the strength 
of 4 D will have a focal length of 1-4 that of a lens of i D— -/. e., 

i^^2-^^ =0.25 cm. (see above. Numbering of Trial-Lenses). Similarly, 

4 
/J = - and a = - ; P representing the distance of the Near Point,, and 

A the focal length of the lens which represents the Accommodation. 



im 
4 



ACCOMMODATION. 



23 



is represented by the convex lens, is termed the negative part; 
while the positive part is represented by the concave lens, and 
has not been brought into play. For sustained accommodation 
at any distance it is necessary that the positive part of the rela- 
tive amplitude of accommodation be considerable in amount. 

Moreover, the convergence may be altered, while the same 
effort of accommodation is maintained, as is shown by the experi- 





FiG. 6. 



Fig. 7. 



ment of placing a weak prism with its base inwards before one 
eye. In order that the object may then be seen singly, it will be 
necessary for the eye before which the prism is placed to rotate 
somewhat outwards ; and it will be found that the individual can 
do this, while at the same time he sees the object with the same 
distinctness, showing that the same effort of accommodation has 
been maintained, although the angle of convergence of the visual 
axis is less than before. 



24 DISEASES OF THE EYE. 

The Meter Angle. 

If the visual line (£ i, Fig. 6) of an eye (E) have to be brought to 
bear on a point (i, Fig. 6) i meter distant from it in the median line 
(M i), the angle of convergence (E i M) which the visual line thus 
makes with the median line is called the Meter Angle. It expresses the 
degree of convergence necessary for binocular vision at that distance, and 
is employed as the unit for expressing other degrees of convergence. If, 
for example, an object be situated i-2 a meter (i-2, Fig. 6) from the eye, 
the angle of convergence {E i-2 M) must be practically twice as large as 
at I meter: C. (Convergence = 2 meter angles. If the object be only 1-3 
of a meter distant, 3 meter angles are required: C. = 3 meter angles. If 
the object be situated 2 meters from the eye, the angle of convergence will 
be only one-half as great as at i meter, and here C. = 1-2 meter angle; 
while if the eye be directed towards a distant object (D) there will be no 
angle of convergence, and if the visual lines be divergent the meter angle 
A^ill be negative. 

Now the average normal emmetropic eye requires for each distance of 
binocular vision as many meter angles of convergence as it requires diop- 
trics Q>i accommodation. For a distance of i meter an efifort of accommo- 
dation of I dioptry is required, and also i meter angle of convergence; at 
1-2 meter from the eye 2 D of accommodation is required and 2 meter 
angles; at 1-3 meter from the eye 3 D of accommodation and 3 meter 
angles, and so on; while for distant objects neither angle of convergence 
nor effort of accommodation is required. 

The Angle Gamma. 

The Optic Axis is an imaginary line (P' P, Fig. 7) which pas'ses through 
the center (C) of the cornea and the posterior pole (F) of the globe — 
a point situated between the macula lutea (M) and the optic papilla (D). 
The Visual Line {M O) unites the point of fixation (O) — the object 
looked at — with the macula lutea; it does not coincide with the optic 
center {K) of the eye. The Line of Fixation {R 0) joins the center of 
rotation {R) of the eye with the point of fixation. The Angle y is the 
angle O R P' formed at the center of rotation by the optic axis and the 
line of fixation. 

The line of fixation and the visual line so nearly coincide that in 
practice we regard them as identical ; and hence, in practice, the angle y 
is the angle O K P' . It should not be confounded, as is often the case, 
with The Angle Alpha, which is the angle O K C formed at the nodal point 
by the visual line and the major axis (C K) of the corneal ellipse. This 
axis rarely passes through the center of the cornea ; but, as it never lies 
far from the latter, the difference in dimension between the two angles is 
very slight. 

In order to measure the angle y the eye is placed at the perimeter as 
for an examination of its field of vision. By means of the corneal re- 
flection of a candle fl'ame, which latter is moved along the arc of the 
perimeter, the center of the cornea is found. The position of the flame 
at the perimeter then gives the angle y. The average size of the angle 
y is 5"- 



THE SENSE OF SIGHT. 25 



THE SENSE OF SIGHT. 

The Sense of Sight consists of three Visual Perceptions or 
Sub-Senses — namely, the Light-Sense, the Color-Sense, and the 
Form-Sense. 

The Light-Sense is the power the retina, or the visual center, 
has of perceiving gradations in the intensity of illumination. A 
convenient clinical method of testing the light-sense is the pho- 
tometer invented by Messrs. Izard and Chibret. On looking 
through this instrument towards the sky two equally bright discs 
are seen. By a simple mechanism one of the discs can be made 
darker. If the eye does not perceive the difference in illumina- 
tion between the two discs within 5° its light-sense is abnormal, 
or we may say its L. D. (Light Difference) is too high. Again, 
if one disc be made quite dark, and be then gradually lighted, the 
patient is required to indicate the smallest degree of light, or 
L. M. (Light Minimum), by which he can observe the disc issu- 
ing from the darkness. This should not be more than 1° or 2°. 

Another good method is that of Bjerrum, in which the light- 
sense is tested by gray letters on a white ground, the letters being 
constructed on the same principle as Snellen's Test Types. 

The Color-Sense is the power the eye has of distinguishing 
light of different wave-lengths. According to the Young-Helm- 
holtz theory, the retina possesses three sets of color-perceiving 
elements, those for Red, Green, and Blue or Violet. These are 
termed primary colors, all other colors being compounds of them. 

According to Hering's theory, the color-sense and the light- 
sense depend upon chemical changes in the retina or in the 
" visual substances " situated in the retina. He suggests the 
existence of three different visual substances, the white-black, he 
red-green, and the blue-yellow, by the using up or Dissimilation, 
and restoration or Assimilation, of which substances the sensa- 
tions of light and color are produced. In the case of the white- 
black substance the sensation of white, or of light, corresponds to 
the process of dissimilation ; while the sensation of black, or of 
darkness, corresponds to the process of assimilation. For the 
red-green and blue-yellow substances it cannot be said which 
color-sensation implies assimilation and which dissimilation. The 
members of the black-white pair can mingle with each other and 
with those of the other two pairs ; but the respective members 



26 DISEASES OF THE EYE. 

of the two-color pairs (being " contrast colors "), e. g., blue and 
yellow, cannot unite with each other. 

In testing the color-sense the spectral colors are the best for 
exact experiments, but the difficulty of producing them at every 
moment, and of combining them, renders them of little chemical 
use. 

The clinical method commonly employed for testing the color- 
sense is that of Professor Holmgren, of Upsala, which is based 
upon the Young-Helmholtz theory. The test-objects used are 
colored wools, of which a large number of skeins of every hue 
are thrown together. 

Test I. {vide card on inside of end cover) consists in present- 
ing to the individual, in good diffused daylight, a pale but pure 
green sample, and requiring him to select out of the bundle of 
wools of all colors before him all of those samples which seem to 
him to correspond to the test sample. If he does this correctly 
it is unnecessary to proceed further: the individual has normal 
color-sense. Amongst the skeins, however, there are some which 
are termed colors of confusion (grays, bufifs, straw-color, etc.) ; 
and if he select one, or several, of these he is color-blind. 

If, now, we desire to ascertain the kind and degree of his de- 
fect we proceed to Test Il.a.. A pink (mixture of blue and red) 
skein is given to be matched. If this be corectly done, we term 
the person incompletely color-blind ; but if blue and violet, or one 
of them, be selected, he is red-blind (sees only the blue in the 
mixture of blue and red) ; if he select green or gray, or one of 
them, he is green-blind. 

In order to corroborate the investigation we may employ Test 
11.^. A vivid red skein is given. The red-blind chooses, besides 
red, green and brown shades darker than the red ; while the 
green-blind chooses green and brown shades lighter than the red. 
But I believe myself, and I think it is now very generally recog- 
nized, that red-blindness and green-blindness invariably go 
together. In violet (or blue) blindness purple, red, and orange 
will be confused in Test Il.a; but this is an extremely rare variety 
of color-blindness. Total color-blindness will be recognized by 
a confusion of all shades having the same intensity of light, and 
is also rare. It is impossible by this test for any color-blind per- 
son to escape detection, except in the case of a small central color 
scotoma. 

The individual tested should not be allowed to name the colors, 



THE SENSE OF SIGHT. 27 

but merely to match them, as above described. The reason for 
this is twofold. First, because, although the congenitally color- 
blind person is usually unaware of his defect, yet experience has 
taught him which of his sensations are called blue, red, etc., by 
other people; and hence he can often apply the right names to 
colors which he really does not see as such. He is assisted in this 
by whatever of color-sight is left to him and by the brightness 
and saturation of the different colors, but is liable to frequent 
mistakes. Again, when the color-blind person does happen to 
know of his defect he is often desirous of conceaHng it, either 
because he is ashamed of it or from interested motives.* 

Edridge-Green's theory ^ is that light falling upon the retina 
liberates the visual purple from the rods, and a photograph is 
formed. The decomposition of the visual purple by light chemic- 
ally stimulates the ends of the cones, and a visual impulse is set 
up, which is conveyed through the optic nerve fibers to the brain. 
He assumes that the visual impulses caused by the different rays 
of light differ in character just as the rays of light differ in wave 
length. Then in the impulse itself we have the physiological 
basis of color. He also assumes that the quality of the impulse 
is perceived by a special perceptive center within the power of 
perceiving differences possessed by that center or portions of 
that center. 

Edridge-Green divides the color-blind into two distinct classes, 
independent of each other, but which may be associated. The 
first class includes those who are not able to see certain rays of 
the spectrum; their spectrum is shortened at one or both ends. 
If an individual have shortening of the red end of the spectrum, 
he will not be able to see a red light at a distance, though he might 
be able to pick out all the green wools in Holmgren's Test I. A 
man of this kind, when shown the red light of Edridge-Green's 
Lantern Test, declares that there is no light visible, thus at once 
demonstrating his incapacity. The second class of the color- 
blind make mistakes, not because they cannot perceive a certain 
color, but because they are not able to recognize the difference be- 
tween the colors, which is evident to normal-sighted persons. 
Normal-sighted persons see six definite colors (points of differ- 
ence) in the spectrum. The second class of the color-blind see 
five, four, three, two, or one color, according to the degree of the 

* More detailed information and Holmgren's test will be found in 
Appendix I. 



28 DISEASES OF THE EYE. 

defect; and they confuse the colors of the normal-sighted, which 
are included in one of their own. If the normal-sighted be desig- 
nated hexachromic, those who see five colors may be called penta- 
chromic ; those who see four, tetrachromic ; those who see three, 
trichromic; those who see two, dichromic; and the totally color- 
blind, monochromic. 

Edridge-Green uses two tests — a Classification Test and a 
Lantern Test. The Classification Test consists of a number of 
colored wools, silks, cards, and glasses, with four test-colors — 
orange, violet, blue-green, and red. The examinee is asked to 
name the test-colors, and then to pick out from the pile all of 
similar color. The Lantern Test consists of a lantern and colored 
glasses, which can be shown alone, or combined or modified by 
neutral glasses. The examinee is asked to name the color of the 
light shown. Edridge-Green is of opinion that the use of color 
names is absolutely necessary, or normal-sighted persons will be 
rejected, through paying attention to shade rather than to color. 
It does not matter what name is applied to a color ; but ground 
for rejection is afforded when the examinee calls two of the main 
colors of the normal-sighted, as, for instance, red and green, by 
the same name. 

A certain proportion of people (3.5 per cent, of men and less 
than I per cent, of women) are congenitally color-blind in greater 
or less degree, without any diminution in the other visual 
functions. 

Acquired color-blindness is found in toxic amblyopia, in 
atrophy of the optic nerve, and under some other conditions. 

The Form-Sense (Acuteness of Vision) is the faculty the 
eye possesses of perceiving the shape or form of objects, and in 
clinical ophthalmology the testing of this function is an important 
and ever- recurring di ty. 

In order that an individual may have good use of his eyes it is 
necessary, not only that the optic nerve, retina, chorioid, and re- 
fracting media be healthy, but also that the refraction and ac- 
commodation be normal. When applied to by a patient on ac- 
count of imperfect sight it is our first duty, as a rule, to ascertain 
accurately the condition of refraction and accommodation of his 
eyes. Should these be abnormal, and it be found that by aid of 
the correcting glasses perfect vision is obtained, we may in general 
conclude that the eye is organically sound, and that the patient's 
complaints are due to the defect in accommodation or refraction. 



THE SENSE OF SIGHT. 29 

If the glasses do not restore perfect vision we must then, by the 
ophthalmoscope and other methods, decide the nature of the 
defect. 

By Acuteness of Vision (V.) is meant the power which an eye, 
or rather its macula lutea, has of distinguishing form, any an- 
omaly of its refraction, if such exist, having been first corrected, 
i. e., while the patient wears the correcting glasses. 

Now, in order to measure the acuteness of vision we must have 
a normal standard for comparison — i. e., we must find what is the 
size of the smallest retinal image whose form can be distinguished. 
We cannot, of course, measure this image on the retina directly ; 
but, as its size is proportional to the visual angle — the angle 
which the object subtends at the eye — it is sufficient to determme 
the smallest visual angle under which the form of an object can 




Fig. 8. 

be distinguished. It has been found, experimentally, that the 
average size of this angle is 5'. 

In order practically to ascertain the degree of acuteness of vision, 
we place our patient with his back to the light, while facing him 
at a distance of 6 meters, and in good light, are placed Snellen's 
Test-Types for distance. These types are so designed that at 
the distance at which they should be seen they each subtend an 
angle of 5' at the eye. The largest type should be seen at 60 
meters (Fig. 8) by the normal eye, and the types range from this 
down to a size visible not farther off than 6 meters. If V := 
Acuteness of Vision, d = the distance from the eye to be tested to 
the test-types, and D = the distance at which the type should be 
distinguishable, then V = 5. For example: if d = 6 meters (a 
distance which most rooms can command), and if the eye see type 
D == 6, then V = f = i, or normal V. ; but if at 6 meters the eye 
see only D := 60, which should be seen at 60 meters, then V = -g%, 
or very imperfect vision. 



30 DISEASES OF THE EYE. 

Should the patient's sight be so bad that he is unable to read 
any of the letters, it may be tested by finding at what distance he 
can count the surgeon's fingers ; and if he cannot even do that, 
then his power of perception of light (his P. L.) should be tested. 
This is done by means of a lamp in a dark room, the eye being al- 
ternately covered and uncovered, and the patient being required to 
say when it is '' light " and when '' dark." If the flame be gradu- 
ally lowered the smallest degree of illumination perceptible will be 
ascertained. 

The eyes must be examined separately, that one not under ex- 
amination being excluded from vision by being shaded with the 
patient's own hand or other suitable screen ; but it must not be 
at all pressed on, as any pressure would dim its vision when 
its turn for examination may come. 

With the advance of age the acuteness of vision undergoes a 
slight but steady reduction, owing to certain senile changes in the 
eye. 

THE FIELD OF VISION. 

By the Field of Vision (F. V.) is meant the space within which, 
when one eye is closed, objects can be seen by its fellow, the gaze 
of the latter being fixed the while on some one object or point. 
Thus if, standing on a hill, we fix the gaze of one eye on some 
object on the plain below, the field of vision includes not only that 
object, but many others also for miles around it. If the fixation 
object be nearer to us, the area taken in by our field of vision will 
be proportionately diminished in extent. 

The fixation object is seen by central or direct vision, its image 
being formed on the macula lutea ; the other objects in the field of 
vision correspond with as many different points in the more 
peripheral parts of the retina, and are seen by eccentric, or in- 
direct, vision. Eccentric vision is of great importance for the 
guiding of ourselves and avoiding obstacles in our way. Its 
use may be realized by the experiment of looking through a 
long small-bore cylinder {e. g., a roll of music) with one eye, thus 
cutting off its eccentric field, while the other eye is closed. 

The Dimensions of the Field of Vision may be measured for 
clinical purposes by means of an instrument called the perimeter. 
This is a semicircular metal band, which revolves upon its middle 
point, being in this way capable of describing a hemisphere in 



THE FIELD OF VISION. 



31 



space. The arc is divided into degrees marked on it, from 0° 
placed at its middle point, to 90° at either extremity. At the center 
of the hemisphere is situated the eye under examination, while the 
fixation point is placed exactly opposite, in the center of the semi- 
circle, at 0°. A small bit of white paper 5 mm. square, the test 
object, is slowly moved along the inner surface of the arc from 
the periphery towards the center, until it comes into view, and 




Fig. 9-— Chart of F. V. of Right Eye. 



thrs point is observed in various meridians. The horizontal, verti- 
cal, and two intermediate meridians, at the least, should be ex- 
amined by placing the arc of the perimeter in the corresponding 
planes. 

The boundary of the field may be noted on a diagram or chart 
(Fig. 9), which represents the projection of a sphere on a plane 
surface. The radii represent dififerent meridians, which may be 
determined by a dial with pointer on the back of the perimeter, 



32 



DISEASES OF THE EYE. 



while the concentric circles correspond with the degrees marked 
on the arc. A pencil mark is placed on the chart at the spot cor- 
responding to that on the perimeter at which the test object comes 
into view, and when the different meridians have been examined 
these marks are united by a continuous line, which then repre- 
sents the outer boundary of the F. V. 

The normal F. V. is not circular, but extends outwards about 
95°, upwards about 53°, inwards about 47°, and downwards about 
65°, as represented by the strong curve in Fig. 9. The limitation 
upwards and inwards is partly due to the projection of the supra- 




FiG. 10. 



orbital margin and the bridge of the nose, but also to the fact that 
the outer and lower parts of the retina are less practiced in see- 
ing than are the upper and inner parts, and their functions conse- 
quently less developed. The acuteness of vision diminishes pro- 
gressively towards the periphery of the field, two points of a certain 
size close together being distinguishable from each other only a 
short distance from the fixation point, while the farther towards 
the periphery the larger must be the test objects. 

Fig. 10 serves to illustrate the projection of the field of vision 
on the semicircle of the perimeter to its extreme temporal (95°) 



THE FIELD OF VISION. 33 

and its extreme nasal (47°) boundaries, as well as the portion of 
the retina (a to b) which corresponds to this extent of field ; and it 
shows that the sensitive portion of the retina, or rather perhaps 
the portion of the retina which is most used, extends farther for- 
ward on the nasal than on the temporal side. The diagram also 




Fig. II (Landolt). — Chart of F. V. of Left Eye. 

explains the remarkable fact that the field extends in the temporal 
direction more than 90°. 

It must be remembered, too, that the fields of vision overlap, as 
the two visual axes meet at the fixation point. Fig. 12 repre- 
sents the binocular portion white, P. being the fixation point. The 
shaded portion on the right belongs to the right eye alone, while 
that on the left belongs to the left eye alone. 

The Blind Spot of Mariotte is a small blind island or scotoma 
in the F. V., situated about 15° to the outer side of the point of 



34 



DISEASES OF THE EYE. 



fixation and just below the horizontal meridian. It is shown 
as a white spot in Fig. 12. It is due to the optic papilla (optic 
disc), for at that place the outer layers of the retina are wanting, 
and hence there is there no power of perception. There are also, 
occasionally, minute blind spots in the field, due to large retinal 
vessels, which interfere with the formation of the image upon 
the layer of rods and cones. 

The Perception of Colors in the Periphery of the Field can be 
examined with the perimeter, by means of bits of colored paper 5 
mm. square. It has been in this way ascertained that the bound- 
aries of the power of eccentric perception for the different colors 
do not seem to correspond with the boundary for white light, nor 
do the boundaries of the different colors seem to coincide. Ex- 




Fig. 12. — Binocular Field of Vision. 



amining from the periphery towards the center by ordinary day- 
light, blue is the color which can be distinguished as such most 
eccentrically, its field extending nearly as far as the general F. V. ; 
then come yellow, orange, red, and, with the most limited field", 
green. Blue, red, and green being the most important, their 
fields are noted in Fig. 11. Although the respective colors are dis- 
tinguishable within the limits indicated, they are by no means so 
brilliant in hue as when seen by direct vision. It has, however, 
been demonstrated that every color is recognizable up to the outer 
limit of the F. V., if the colored object be of sufficient surface and 
be sufficiently illuminated; so that there is, in fact, no absolute 
color-blindness in the peripheral parts of the retina, but merely a 
diminished sensitiveness to colored light. 



THE FIELD OF VISION. 35 

The Perception of Form m the Periphery of the Field is very 
defective, and its examination is not of much practical importance ; 
but this portjon of the field is very sensitive to the movement of 
objects. 

References. 

^ " Optique Physiologique," pp. 158-167. 

^ " Color Blindness and Color Perception : International Scientific 
Series." 
^ " Von Graefe's Archiv," xxxix. 2. p. 71. 



CHAPTER II. 

ABNORMAL REFRACTION AND ACCOMMODATION. 

I HAVE explained what is meant by Normal Refraction, or Em- 
metropia. We recognize three different forms of Abnormal Re- 
fraction, or Ametropia {a^ priv.; fxerpoi^y standard; oof), i. Hy- 
permetropia (vTtsp, over; juhpov, standard; cof), in which the 
principal focus of parallel rays of light lies behind the retina. 2. 
Myopia ( mjetv, to close; ooip), or Short-sight, in which the 
principal focus of such rays lies in front of the retina. 3. As- 
tigmatism {a, priv.; atiy)j.a,a point), in which the refraction of 
the eye in its different meridians is different. 

Hypermetropia. 

In a large proportion of cases this form of Ametropia is due to 
the eyeball being too short in its antero-posterior axis (Axial H.). 




Fig. 13. 

It may also depend upon deficient refracting power in the dioptric 
media (Curvature H.). 

Parallel rays of light (a h. Fig. 13) falling into the hyper- 
metropic eye (£) do not meet on the retina, but converge towards 
a point (c) situated behind it. Consequently these rays do not 
form on the retina a distinct image of the object looked at, but 
produce there a circle of diffusion {d e), or blurred representation 
of the object. 

36 



HYPERMETROPIA. 



37 



Since, therefore, in hypermetropia the retina is in front of the 
principal focus of the dioptric system, rays passing out of the eye 
from any point (R, Fig. 14) on this retina will pass out as diver- 
gent rays (f g), and will appear to come from a point (R') situ- 




FiG. 14. 

ated behind the eye, which point is the virtual conjugate focus of 
the point R. 

Now in order to correct the hypermetropia — so that parallel 
rays (a b, Fig. 15) passing into it may be brought to a focus on 
the retina — a convex lens (L) must be placed in front of the eye, 
of sufficient strength to render the parallel rays, before they enter 




Fig. 15. 



the eye, convergent towards R\ so that when they meet the eye 
they may be brought to a focus on the retina R, which is the con- 
jugate focus of R'. The higher the hypermetropia — i e., the 
shorter the antero-posterior axis of the eyeball — the stronger must 
the correcting glass be. It may be found that, with a lens of some 
dioptrics less power, the eye will see equally well ; but this it does 
by means of an effort of accommodation, which supplements the 
inadequate refracting power of the lens placed before it. As 



38 DISEASES OF THE EYE. 

we proceed to higher lenses the effort of accommodation is relaxed, 
until, finally, the strongest lens with which vision is still at its best 
is reached when, it may for the present be assumed, no further 
effort of accommodation is made, and L represents the whole error 
of refraction. 

In low degrees of hypermetropia the eye can frequently see 
distant objects distinctly by an effort of accommodation, which 
completely takes the place of L. When such an eye is found to 
have full vision without a glass, a beginner may fall into the error 
of regarding it as emmetropic ; but if he will take the precaution 
of placing a low convex lens in front of it, and then finds that the 
acuteness of vision remains as good as without the glass (be- 
cause the effort of accommodation is now relaxed), he will avoid 
this mistake, unless there should be tonic cramp of accommodation, 
which might partially, or even completely, mask the hypermetro- 
pia. 

If a glass a single number higher than the exact measure of 
the defect be placed before the eye, vision again becomes indistinct, 
because the rays are then brought to a focus in front of the retina, 
and a circle of diffusion is formed on the latter. The eye, in fact, 
is put by such a glass in a condition of myopia. Therefore the 
strongest convex glass with which a hypermetropic eye can see 
distant objects (the test-types) most distinctly is the glass which 
corrects its hypermetropia, and is the measure of the latter. Very 
commonly it is only the manifest hypermetropia (vide infra) 
which is ascertained by this method, unless the accommodation 
has been previously paralyzed by atropin. 

This method of determining the refraction by means of the trial- 
lenses and test-types is not relied on now-a-days by ophthalmic 
surgeons to the same extent as formerly, the examination of the 
upright ophthalmoscopic image, or else retinoscopy, the use of 
which will be explained later on, having largely taken its place. 
In conjunction with these it is a valuable method. 

The degree of the hypermetropia is indicated, as has been said, 
by the number of the lens which corrects it.* Thus, if the num- 
ber of the glass (L, Fig. 15) required to correct the hypermetropia 

* Theoreticlally the glass which measures the error of refraction should 
be in contact with the eye, but for practical purposes the distance 
between the glass and the eye may be neglected, especially if the glasses 
are worn at the same distance from the eye as they occupied during the 
testing. 



I 



HYPERMETROPIA. 39 

of the eye (E) be 2.0 D, we say this eye is hypermetropic two 
dioptries, or has a hypermetropia of two dioptries, or we would 
write it down H — 2.0 D. 

Amplitude of Accommodation in Hypermetropia. — When at rest the 
refraction of the hypermetropic eye is deficient : consequently r must be 
negative ( — r), and the amplitude of accommodation must include the 
power required to adapt the eye to infinity; therefore 
a = p — { —r) = p -\~ r. 

For example : if the punctum proximum of a hypermetropic eye of 5 D 
be at 30 cm., what is the amplitude of accommodation? 5 D ( ^ r) is 
necessary in order to make the eye emmetropic, and to accommodate the 
emmetropic eye to 30 cm. 3.25 D (W- = 3-25) is required. Hence a = 
3.25 + 5=8.25 D. 

The Angle y in Hypermetropia. — In hypermetropia, as in emmetropia, 
the cornea is cut to the inside of its axis by the visual Hne ; but in hyper- 
metropia the angle which the visual line forms with the axis of the cornea 




Fig. 16 (right eye). 

is very much greater, owing to the shortness of the eyeball, the effect of 
which is to increase the distance between the macula lutea (M) and the 
optic axis (A, Fig 16). Consequently, in extreme cases, when the two 
visual lines of a hypermetropic individual are directed to an object, the 
axes of the corneee may seem to diverge, and thus the appearance of a 
divergent strabismus will be given (apparent strabismus, see chap, xviii.). 

The eyes of animals and of uncivilized nations are hyper- 
metropic; children, too, are hypermetropic at birth, but as they 
grow older the refraction increases, and they become less hyper- 
metropic, or emmetropic, or even myopic. 

The evil effects of the constant and excessive demand upon the 
accommodation in hypermetropia are chiefly these: 

I. Cramp of the Ciliary Muscle. — Its persistently maintained 
contraction frequently gives rise to a tonic cramp of the muscle. 
This spasm is not, or may be only partially, relaxed when the cor- 
recting convex glass is held before the eye, and consequently the 



40 DISEASES OF THE EYE. 

whole or part of the hypermetropia may be masked by the cramp. 
That part of the hypermetropia which is thus masked is called la- 
tent (HI.), while the part which is revealed by the convex glass is 
called manifest (Hm.). The entire hypermetropia is made up of 
the latent and manifest H. (H = Hm.-j- HI.). 

If the cramp be excessive, parallel rays may be kept convergent 
on the retina by it alone, and vision then would be made worse, 
rather than better, by even a weak convex glass held before the 
eye, a circumstance which might lead the surgeon to think he had 
to do with an emmetropic eye. In this case we say that the whole 
hypermetropia is latent. 

Or, in extreme cases of accommodative spasm, parallel rays may 
be united in front of the retina, and the eye made apparently my- 
opic, the vision being capable of improvement by concave glasses. 
Serious errors might therefore arise if this cramp were overlooked, 
as it is very apt to be in the examination with the trial-lenses. 
When it is present in a high degree, the patient cannot maintain 
a sustained view of an object at any distance without suffering 
pain in and about the eyes. It is frequently the reason why per- 
fect acuteness of vision is not obtained by aid of the trial-lenses, 
and the surgeon must be careful not to be led into an error of 
diagnosis by it. Examination with the ophthalmoscope, or pa- 
ralysis of accommodation with atropin, will enable him to avoid 
mistakes. 

In order to relieve this cramp, the ciliary muscle must be par- 
alyzed by a solution of atropin freely instilled; and it will often 
be necessary to keep the accommodation paralyzed for some days, 
and to commence the use of the correcting spectacles before the 
effect of the atropin begins to wear off. In this way a recurrence 
of the spasm may be often prevented. 

As life advances, and the power of accommodation diminishes, 
the manifest part of the hypermetropia increases, while the latent 
part decreases, until finally Hm. = H. 

2. Accommodative Asthenopia (a, priv.; a^ero?, strength; 
GDip). — In looking at distant objects the accommodation of the 
emmetropic eye is at perfect rest, and does not come into play 
until the object is approached close (within 6 m.) to the eye. But 
even for distant objects the hypermetropic eye must accommo- 
date ; and, having for those distances used up part of its accommo- 
dative energy, it has for near objects actually less at disposition 
than the normal eye. Hence we find that hypermetropic people 



HYPERMETROPIA. 41 

often complain of inability to sustain accommodative efforts for 
near objects for any length of time. After reading, sewing, etc., 
for a short time, sensations of pressure in the eyes and of weight 
above and around them come on, and the words or stitches become 
indistinct, and cannot be distinguished. The work must then be 
interrupted, and after a few minutes' rest it can be resumed, but 
must soon again be given up. After a Sunday's rest the patient 
is often able to get on better than on the previous Saturday. These 
symptoms depend simply upon inability of the ciliary muscle to 
perform the excessive demands made upon it. 

Accommodative Asthenopia often appears suddenly during or 
after illness, the explanation being that, although hypermetropia 
had always existed, yet in health the ciliary muscle was equal 
to the great efforts required of it, but in sickness it shared the de- 
bility of the system in general. 

3. Internal, or Convergent Concomitant Strabismus. — This 
condition has a certain relation to hypermetropia. It will be 
treated of in the chapter on the Motions of the Eyeballs and their 
Derangements (chap xvii.). 

The Prescribing of Spectacles in Hypermetropia. — If a per- 
son be found to be hypermetropic, but his acuteness of vision with- 
out glasses be good, or as good as he desires, and he complain 
of no asthenopic symptoms, glasses need not, indeed should not, be 
prescribed for him. No disease in his eye will result from his 
going without glasses. 

If the patient complain of imperfect distant vision due to 
hypermetropia, then those lenses which correct the Hm. may be 
prescribed for distant vision, to be worn either constantly or 
occasionally, as he may desire. Such a patient is almost certain 
to complain also of accommodative asthenopia ; while many pa- 
tients will be met with who complain of the latter, yet express 
themselves as perfectly satisfied with their distant vision. For 
relief of the asthenopia it is usually enough to prescribe spectacles 
for near work which will correct the Hm., along with i D or 2 D 
of the HI., if the latter exist. 

If there be excessive cramp of accommodation, glasses to cor- 
rect the whole hypermetropia should be worn while the eye is 
under atropin; and afterwards as much of the HI. as possible, 
along with the Hm., should be corrected by glasses to be worn 
constantly. 



42 



DISEASES OF THE EYE. 



Myopia^ or Short-Sight. 

Tliis form of ametropia is due, in a vast majority of cases, to 
the antero-posterior axis of the eyeball being too long (Axial M.), 
and hence, its refracting media not being proportionately dimin- 
ished in power, parallel rays of light (a b, Fig. 17) are not brought 




Fig. 17. 

to a focus on the retina, but in front of it (at /) and form on the 
retina circles of diffusion {c d). 

Myopia may also be caused by abnormally high refracting 
power in the crystalline lens, as in spasm of the ciliary muscle, and 
in some cases of commencing cataract, and also by conical cornea 
(Curvature M.). 

Since, in the myopic eye, the retina is beyond the principal focus 




Fig. 18. 



of the dioptric system, rays' emerging from any point {c, Fig. 18) 
of the fundus will pass out convergently, and will unite in front 
of the eye at the conjugate focus of the retina (r). 

Conversely, rays diverging from a certain point (r, Fig. 18) in 
front of the eye will be focused on the retina (c). 



MYOPIA. 43 

If an object be brought towards the eye, the divergence of 
those rays which pass from it into the eye increases until, when 
it has reached the point r, their divergence is just sufficient to al- 
low them to be united at the conjugate focus {c), which is on the 
retina. This point r is the punctum remotum* of the myopic eye. 
In order, therefore, that the short-sighted eye may be able to see 
distant objects, it is necessary that the parallel rays (a h, Fig. 19) 
coming from those objects should be given such a degree of di- 
vergence before they pass into the eye as though they came from 
this punctum remotum. This can readily be effected by placing 
the suitable concave lens (L) in front of the eye, and the number 
of this glass will indicate the degree of the myopia — i. e., by how 
many dioptrics the refracting power of the eye is in excess of that 
of an emmetropic eye. The focal length of the correcting glass 
Corresponds, of course, with the distance of the punctum remotum 




Fig. 19. 

(r)from the eye, provided the glass be held close to the cornea. 
The focus of the glass and the punctum remotum of the eye are 
then identical, and, therefore, parallel rays, after passing through 
the glass, will have a divergence as though they came from the 
punctum remotum, and will form an exact image of the object 
from which they come on the retina. 

For example: if the punctum remotum (Fig. 19) be situated 
at 14 cm. from the eye, then the number of the correcting lens 

* The punctum remotum is always the conjugate focus of the retina. 
In an emmetropic eye it is at infinity, since the retina is at the principal 
focus of the eye, and the rays pass out parallel. In hypermetropia it is 
behind the eye, and is virtual or negative, because the retina is in front 
of the principal focus, and the rays pass out divergently, as if coming 
from a point behind the retina. Lastly, in myopia it is situated at a 
finite distance in front of the eye, and is real and positive, because the 
retina is beyond the principal focus, and the rays emerge convergently. 



44 DISEASES OF THE EYE. 

will be 7 D, because the focal distance of this lens is 14 cm. (Yi*^ 
= 7). In practice, however, we cannot hold the glass so close 
to the cornea, and, therefore, we must subtract the distance be- 
tween it and the cornea from the focal distance of the required 
lens. In the above case, suppose the distance from cornea to glass 
be 4 cm., the required lens in practice will be 10 D (-Yo^- = 

10). 

Determination of the Degree of Myopia. — The degree, or 
amount, of myopia, as of hypermetropia, may be determined either 
by the ophthalmoscope, or experimentally by means of the trial- 
lenses and test-types. 

By the latter method, examining €ach eye separately, we find the 
correcting glass by placing our patient as directed in the section on 
Acuteness of Vision (p. 29). A weak concave trial-glass is then 
held before the eye under examination, and higher numbers are 




Fig. 20. 

gradually proceeded to until the glass is reached which gives 
the eye the best distinguishing power for the types. We often find 
that there are several glasses, with each of which the patient can 
see equally well. The weakest of these is the measure of his my- 
opia^ When a higher glass is used the eye may still see well, but 
it does so only by an effort of accommodation (i. e., the crystal- 
line lens has to be made more convex in order to compensate for 
the excessive concavity of the glass placed in front of the eye), 
and the glass employed represents then not merely the myopia 
present, but also this accommodative effort. No more serious mis- 
take can be made than the prescribing of too strong concave 
glasses for a myopic individual, as will be seen further on. 

The Amplitude of Accommodation in Myopia. — The myopic eye has an 
excess of refractive power as compared with the emmetropic eye; there- 
fore, in calculating its amplitude of accommodation, this excess must be 



MYOPIA. 45 

subtracted from the positive refractive power (/>) which would be required 
to adapt the emmetropic eye to the same punctum proximum ; or, in other 
words, the myopic eye has need of less accommodative power than the 
emmetropic eye, because, even at rest, it is adapted for a distance (R., its 
punctum remotum) for which the emmetropic eye has to accommodate; 
hence in myopia 

a = /) — r. 

For example : a myopic person of lo D who can accommodate up to 8 cm. 
(/)z=i|^=i2 D) has an amplitude of accommodation of 12 — 10 = 2 D. 
The Angle y in Myopia. — In myopia, owing to the length of the eye- 
ball, the cornea is cut much closer to its center by the visual line than in 
emmetropia, or the visual line (M V, Fig. 21) and the optic axis (A O) 
may coincide, or the cornea may even be cut to the outside of its" center by 
the visual line {vide Fig. 20). In any of these cases, but especially in the 
latter, the effect will be that of an apparent convergent strabismus. 

Myopia is rarely congenital. It generally first shows itself from 
the eighth to the tenth year, and is apt to increase, especially dur- 
ing the early years of puberty. Its progressive increase is encour- 
aged by use of the eye for near work, such as reading, sewing, 
drawing, etc., and is due to a further elongation of the antero- 
posterior optic axis. But it is certain that in addition to this ex- 
citing cause there must be some predisposing condition or con- 
ditions, as but few children become short-sighted, although all 
are educated in a very similar manner in so far as the use of their 
eyes is concerned. Moreover, high degrees of myopia are oc- 
casionally met with in young children before they have begun to use 
the eyes much for close work. Stilling ^ and Seggel ^ have found 
that a low orbit is usually associated with a myopic formation of 
eyeball, and they are inclined to regard these largely in the light 
of cause and effect. For with a low orbit, and when, as often 
happens, the tendon of the superior oblique has an almost trans- 
verse direction, the combined pressure of the two obliques upon 
the plane of the equator during the period of growth would tend 
to cause elongation of the antero-posterior diameter of the eyeball. 
Opposed to this view is the fact that in scholars of Esthic nation- 
ality, who have broad faces and low orbits, the proportion of my- 
opes is less than in Europeans. There are many other theories 
as to the causation of short-sight. Certain it is that the tendency 
to myopia is often hereditary, and is frequently seen in several 
members of a family ; but the whole question of the predisposing 
causes of myopia must still be regarded as sub jiidice. 

In cases of commencing cataract a slight degree of myopia may 



46 DISEASES OF THE EYE. 

sometimes be noticed to come on. This is due to a higher refract- 
ing power in the lens, as the result of the changes begmning in it. 

Many short-sighted people half close their eyes when endeavor- 
ing to distinguish distant objects, in order that the rays may be 
prevented, so far as possible, from passing through peripheral 
parts of the crystalline lens, which would increase the circles of 
diffusion. This habit it is which has given the name of myopia 
to the condition (znde p. 36). 

Progressive Myopia frequently becomes complicated with 
Organic Disease, and to the more serious cases the term Per- 
nicious Myopia may be applied. The following are the forms 
of organic disease met with : 

1. Posterior Staphyloma, or Myopic Crescent. — This condition 
is recognized by the ophthalmoscope as a more or less extensive 
white crescent at the outer side of the optic papilla. Owing to 
bulging of the eyeball, the chorioid becomes atrophied at this 
place, and a crescentic portion of the white sclerotic is laid bare. 
The staphyloma sometimes extends all round the optic papilla, and 
by stretching of the retina in extreme cases its functions may be- 
come deranged, and the blind spot increased in size. But every 
case in which a small crescent is present is not to be regarded 
as having a serious bearing. Much here depends on the age of the 
patient and the degree of the myopia. The younger the patient 
and the higher the myopia, the more serious is the outlook. As a 
matter of experience in the majority of cases the short-sight in- 
creases by only a very few dioptrics, and does not become com- 
plicated with the more dangerous forms of organic disease. In- 
fintely more serious than Posterior Staphyloma are the following 
conditions : 

2. Chorioidal Degeneration in the Neighborhood of the Macula 
Lntea. — This should always be carefully looked for, as the region 
of the yellow spot is very liable to disease in the worst cases of 
progressive myopia. The disease seems to begin in the chorioid, 
giving the appearance of small cracks or fissures, which later on 
develop into a patch of chorioidal atrophy. The retina at the 
spot becomes disorganized, and very serious disturbance of vision, 
associated in the early stages with metamorphopsia, is the result, 
the patient being disabled from reading, although, as the periphery 
of the fundus is usually sound, he can find his way about freely. 
Treatment can do little here. Abstention from use for near work 
and the wearing of dark glasses are to be recommended. 



MYOPIA. 47 

3. Chorioidal Exudation in the Neighborhood of the Macula 
Liitea. — A small gray spot of exudation may appear in the chorioid 
at this place, accompanied by loss of sight for reading. These 
cases are often amenable to active mercurial treatment, when sight 
may be restored. Should the case be neglected or run a bad course, 
vision will be permanently damaged from secondary chorioidal de- 
generation. 

4. The Black Spot in Myopia. — This disease also attacks the 
chorioid in the region of the yellow spot, and causes a loss of cen- 
tral vision similarly as in the two previous forms of disease. The 
appearance shown by the ophthalmoscope is that of a black spot, 
usually quite circular and with a defined margin. In the early 
stages its size is much smaller than that of the papilla, but later it 
often attains a dimension of two papilla diameters, or more. The 
spot is rarely of an equal intensity of blackness all over, but 
towards its center a faint reddish hue often shines through in 
places. At a later stage the black spot becomes surrounded by a 
narrow whitish border, while towards its center it becomes less 
black, and finally grayish or even white, its margin remaining 
black. Although small hemorrhages, which often occur in the 
neighborhood of the black spot, gave rise to the opinion that 
the black spot itself was the result of hemorrhage, yet this seems 
not to be so, as the investigations of E. Lehmus^ have shown. The 
diseased changes consist in a proliferation of the pigment epi- 
thelium, combined w^ith a gelatinous exudation, which in the case 
examined had attained a thickness, at the center of the black spot, 
of two-thirds that of the chorioid. The chorioid was but very 
slightly altered, and the glass membrane was quite normal. At the 
margin of the proliferating region the pigment epithelium was 
found to be paler or even quite free of pigment. The black spot 
very gradually, in the course of years, attains its ultimate di- 
mension, and then very slowly retrogresses, until finally its place 
is taken by a grayish or bluish-white scar. Treatment is of no 
avail, and central vision does not becomes restored. 

5. General Chorioidal Atrophy. — In advanced cases of per- 
nicious myopia, large patches of chorioidal atrophy, other than the 
crescent, are often present, chiefly in the region of the posterior 
pole, but very liable to extend also towards the periphery of the 
fundus. The vitreous humor in these cases usually contains many 
opacities. Treatment by means of subconjunctival saline injec- 
tions is occasionally of use in clearing up the vitreous humor, 



48 DISEASES OF THE EYE. 

and thus effecting some improvement of vision. The eyes 
should not be used for near work, and dark glasses should be 
worn. 

6. Hemorrhage in the Retina at the Yellow Spot may occur, 
and when the hemorrhage becomes absorbed the macula lutea 
may not recover its function, owing to the delicate retinal tissue 
having been seriously damaged. Yet we often meet with cases 
of this kind which do regain their former vision. Rest of the eyes 
and dark glasses should be prescribed. 

7. Detachment of the Retina. — This is a frequent and most 
serious complication of progressive myopia. It will be considered, 
in the chapter on Diseases of the Retina (chap. xv.). 

Functional Anomalies attending Progressive Myopia. — 

(a) Insufficiency of the Internal Recti Muscles is almost al- 
ways associated with progressive myopia, but it can hardly be re- 
garded as a result of the latter. It may more properly be 
looked upon as a concomitant congenital irregularity, and per- 
haps as one of the causes of the progressive nature of myopia ; yet 
it is indeed very commonly present in cases of slight myopia, which 
have no tendency to increase. It will be fully discussed in chap, 
xvii. 

(6) Cramp of Accommodation is often present in myopic eyes, 
and will cause the myopia, examined with trial-lenses and test- 
types, to seem higher than it really is. The surgeon, being aware 
of this source of error, will guard against it. 

The Management of Myopia. — In view of the tendency to 
become more short-sighted, to which, especially during adoles- 
cence, nearly every case of short-sight is liable, and of the fact that 
in a given case we cannot tell to what extent this increase may 
go — whether to slight, medium, or high myopia — and, finally, as 
high degrees of myopia almost invariably lead to disease of the 
eye, the management of myopia, including the prescribing of 
glasses for it, is one of the most important matters with which 
we have to deal. 

The Prescribing of Glasses in Myopia. — It is not necessary to 
prescribe glasses for very slight degrees of myopia (up to i.o D 
or 1.5 D) ; yet should the patient desire to wear correcting glasses 
for distant objects, there can be no objection to his doing so. But 
for cases of myopia of 2.0 D or more, it becomes very desirable to 
prescribe glasses which fully correct the myopia, to be worn con- 
stantly — i. e., for both distant and near objects; and, should the 



MYOPIA. 49 

myopia increase, to increase from time to time the strength of the 
glasses accordingly. 

This has not always been the teaching on this point, and 
even yet many ophthalmologists do not prescribe fully correcting 
glasses for their myopic patients, especially for near work. It has 
been held that any effort of accommodation which might be caused 
by fully correcting concave glasses would promote the tend- 
ency to increase of the short-sight, and to chorioidal disease. In 
fact, it was regarded as important to save the myopic eye every ef- 
fort of accommodation in so far as possible. The usual practice 
.was to order a glass 0.5 D, i D or 2 D less than the full correction 
for distant vision ; while, for near work, either no glasses were al- 
lowed, if the myopia was of low degree ; or, if of medium or high 
degree, a separate pair of spectacles, of such strength as would 
merely enable the patient to read ordinary print at about 30 cm. 
from his eye, was given. It was also the practice to restrict the 
use of the myopic eye for near work to a limited number of hours 
daily, with intervals of rest, or even to interdict all near work ab- 
solutely for a period of months at a time. The main object of the 
reading-glass was — the patient being enabled thereby to hold near 
objects farther from his eye — to diminish the angle of convergence 
of the optic axes, and thus to reduce the pressure of the orbital 
muscles on the eyeball during convergence, a pressure which it is 
considered promotes the elongation of the globe. 

We now know, on the one hand, that the action of the muscle 
of accommodation does not produce a pull on the chorioid farther 
back than the equator of the eyeball, while it is, of course, at the 
posterior pole that the diseased processes in myopia commence. 
Nor does the ciliary muscle by raising the tension of the eye, nor 
in any other way, cause an elongation of the eyeball. Hence, there 
is no reason to spare the healthy myopic eye any ordinary effort of 
accommodation. Indeed, it is reasonable to think that if normal 
efforts be required of the ciliary muscle, its more healthy tone will 
improve the general healthy nutrition of the uveal tract, and conse- 
quently will tend rather to avert morbid changes in it. 

On the other hand, the diminution of the angle of convergence 
at near work is a truly important matter, for the reason above 
stated ; but it is more effectually provided for by full than by par- 
tial correction. 

Practical experience is here even more valuable than theory, 
and it shows that in a large majority of those patients whose short- 



50 DISEASES OF THE EYE. 

sight has been fully corrected in youth, and who have worn their 
spectacles contantly for a number of years, the myopia in many 
instances has not increased at all, while in a large proportion the 
increase will have been moderate, and in but a small proportion 
marked pernicious progress will be noted. In short, the tendency 
to increase of the myopia and to organic disease is less than in 
those myopes who have either worn no glasses or only partially 
correcting glasses. 

Well-fitting, properly centered spectacles are much to be pre- 
ferred to folders, which are difficult to keep correctly centered be- 
fore the eyes. Any astigmatism present should always be cor- 
rected. Patients whose eyes are healthy, and who wear constant 
full correction, may be permitted, and even encouraged, to use 
their eyes freely for near work, always keeping the work as far 
from the eyes as possible, to diminish the angle of convergence. 
With this latter object in view, too, well-printed books, ample 
light, and suitable reading- and writing-desks should be provided 
in all educational establishments, and for home studies. 

But in prescribing the full correction for constant wear to young 
short-sighted persons, we meet with some difficulties. The first 
of these is due to the range of accommodation, which is imperfect 
in the myopic eye, and consequently the patients may complain of 
painful accommodative sensations when first using their fully cor- 
recting lenses for near work, and sometimes they decline to persist 
in the attempt. These complaints are more likely to be made by 
patients of about twenty years of age or more, whose habit of use 
of their eyes (relative amplitude of accommodation, and degree 
of convergence) has become more or less confirmed, and in whom 
the power of accommodation has naturally diminished to an appre- 
ciable degree, rather than by persons of from twelve to seventeen 
years of age. Patients should be encouraged, in spite of discom- 
fort, to continue for some time longer to read, etc., with the full 
correction, when, very often, the relative amplitude of accommoda- 
tion will gradually improve, and the discomfort will cease. Or, a 
lower number than the full correction may be ordered, and the 
strength gradually increased, until, in the course of some weeks or 
longer, the full correction can be worn for near work with ease. 

A second obstacle to full correction for constant wear is the 
vanity of the patients, or of their parents, who for the sake of ap- 
pearance dislike the spectacles. Again, the rooted and widespread 
prejudice against '' strong glasses," irrespective of the question 



MYOPIA. 51 

whether those glasses correspond to the degree of the myopia of 
the eyes they are prescribed for or not, will often stand in the way 
of proper advice on this subject being followed. 

Operative Cure of Myopia. — This consists in the removal 
of the crystalline lens, and was first systematically employed by 
Fukala.^ Some surgeons sim.ply extract the clear lens by one of 
the methods used for cataract, while the majority first perform 
discission of the lens, and, when it has swollen and become cata- 
ractous, they proceed to evacuate it through a linear corneal inci- 
sion. Discission pure and simple is, I think, preferable to either 
of these methods, the process of absorption being allowed to go 
on until the whole lens gradually disappears. The opaque lens 
matter is not evacuated through a corneal incision, unless increased 
tension or other complications should make it necessary. I believe 
that discission pure and simple is not only the safest method as an 
operative proceeding, but is also less likely to be followed by any 
intra-ocular complication, such as detachment of the retina, or 
hemorrhage, than where a sudden reduction in the contents of the 
eyeball is effected, as by either of the other methods. Moreover, 
the disfigurement caused by the corneal incision, slight though it 
be, is a drawback from which the simple discission is free. Nor, 
again, is astigmatism so apt to be produced. The cure, by simple 
discission, has the disadvantage of being very slow, but this is 
not a serious drawback in view of the lifelong advantages to be 
gained. 

It is important, whatever the method used may be, to avoid in- 
jury of the vitreous humor, as any such injury may lead to shrink- 
ing of the vitreous, followed by detachment of the retina. 
Whether in these highly myopic eyes their tendency to retinal de- 
tachment is increased by the operation, is a question which has 
been answered by means of statistics, in the sense that the operated 
cases are neither more nor less liable to detachment than the un- 
operated cases. 

The operative cure of myopia is not to be recommended ex- 
cept for cases of 12.0 D and more ; nor should it be performed 
where there is such serious disease of the fundus or vitreous humor 
as would render any improved use of the eye on conclusion of the 
treatment unlikely. Active chorioidal disease is regarded as a 
contra-indication, but small retinal hemorrhages, even if they be 
near the macula lutea, need not be so regarded. The best time of 
life for the cure is in childhood or early youth, but it can be sue- 



52 DISEASES OF THE EYE. 

cessfully undertaken at a much later period. In the myopic eye 
the nucleus of the lens undergoes sclerosis to a less extent than 
in hypermetropia or in emmetropia, and hence in it discission is 
less apt to be followed by high tension or other complication, 
even when performed in middle age. 

The advantages gained by the patient from the operative cure of 
his myopia are enormous. Not merely does the patient become 
either only slightly myopic, or else emmetropic or hypermetropic, 
according to the degree of the original myopia, but his acuteness 
of vision is usually increased in a remarkable degree. One of my 
patients, with M. 20 D and V. = Finger-counting at 2 m., obtained 
after discission and resulting absorption of the lens an emmetropic 
eye, and V. = j\. The cause of this improved acuteness of 
vision is not clearly understood, and in some cases it goes on for 
several months before it reaches its height. Another remarkable 
point, illustrated, too, by the above case, is that the amount of re- 
duction in the refraction of the eye is much greater in these cases 
than one would a priori expect. A convex lens of about lo.o D is 
commonly required to correct an emmetropic eye that has been 
operated on for cataract, which would imply that the refracting 
power of the crystalline lens is about + lo.o D in the emmetropic 
eye. But, after the operative cure of myopia, it is found that the 
reduction in the refraction of the eye amounts to from 12.0 D to 
20.0 D, and varies in different eyes. Convex spectacles require to 
be worn for near work after the operation, and sometimes, too, for 
distant vision where hypermetropia has been produced. Where 
the original myopia is not more than about 12.0 D it is advisable, 
in patients who follow certain callings in which the wearing of 
glasses is objected to, to operate on only one eye, which then sub- 
sequently serves for distant vision, while the unoperated eye is 
used for reading and other near work, and by this means the pa- 
tient is entirely independent of glasses. 

Astigmatism. 

This is a compound form of ametropia, due to the cornea being 
more curved in one meridian than in another, similarly as the back 
of the bowl of a spoon is more convex from side to side than from 
heel to point. 

In Regular Astigmatism the directions of the greatest and least 
curvations of the cornea are always at right angles to each other, 



ASTIGMATISM. 53 

and usually fall precisely in the vertical and horizontal meridians, 
the meridian of greatest curvature being most frequently the ver- 
tical. Consequently, we say the astigmatism is " with the rule " 
in those cases in which the meridian of greatest curvature is the 
vertical; and, where that meridian is the one of least curvature, 
we say the astigmatism is *' against the rule." The result of this 
is that a pencil of rays passing into the eye, instead of meeting at 
a common focus, is irregularly refracted, those rays passing 
through the vertical meridian of the cornea being brought to a 
focus much earlier than those which fall through its horizontal 
meridian ; and therefore at the focus of the former the latter rays 
form a horizontal streak of light. The intermediate, or oblique, 
meridians will probably be of regularly intermediate refracting 
power. 

The interval between the foci of the two principal meridians is 
called the Focal Interval, and is a measure of the astigmatism. 




Fig. 21. 

The accompanying diagram (Fig. 21), after Bonders, will 
assist in the understanding of the course of a pencil of rays after 
they have passed through an astigmatic cornea, those rays belong- 
ing to the horizontal and vertical meridians being chiefly con- 
sidered. 

At A neither vertical (v v') nor horizontal (h h') rays have yet 
been united at their foci, but the vertical rays are the nearest to 
their focus ; and therefore the appearance which the pencil of rays 
would give, if caught here on an intercepting screen, is an oval 
with its long axis horizontal, as shown by the dotted line. At B 
the vertical rays have met at their focus, but the horizontal rays 
not as yet at theirs, and the result is therefore a horizontal straight 
line. At C the vertical rays are diverging again from their focus, 
and the horizontal rays have still not come to theirs. At D the 
same conditions exist, only a little farther on, where the one set of 
rays is diverging, the other still converging, but each at the same 
angle ; hence the shape of the figure is round. At F the horizontal 



54 



DISEASES OF THE EYE. 



rays have met, and the result is a vertical straight line. At G 
both sets of rays are divergent, and the figure is an oval with the 
long axis perpendicular. 

There are various kinds of regular astigmatism, according to 
the position of the two principal foci with reference to the retina, 
as follows : 

. I. Simple Hypermetropic Astigmatism. — When the focus (V, 
Fig. 22) of the vertical rays is situated on the retina (emmetropia 





Fig. 22. 



Fig. 23. 



in that meridian), while that (H) of the horizontal rays lies be- 
hind the retina (hypermetropia in that meridian). 

2. Compound Hypermetropic Astigmatism. — When the foci of 
both sets of rays is behind the retina, that (H, Fig. 23) of the 
horizontal rays is farther back than that (V) of the vertical ravs. 





Fig. 24. 



Fig. 25. 



3. Simple Myopic Astigmatism. — When the focus (H, Fig. 24) 
of the horizontal rays is situated on the retina (emmetropia in that 
meridian), while the focus (V) of the vertical rays is situated in 
front of the retina. 

4. Compound Myopic Astigmatism. — When the foci of both 
sets of rays are situated in front of the retina, but farther forward 
in the case (V, Fig. 25) of the vertical rays. 

5. Mixed Astigmatism. — When the focus (H, Fig. 26) of the 



ASTIGMATISM. 55 

horizontal rays falls behind the retina (hypermetropia in that 
meridian), and the focus (V) of the vertical rays in front of the 
retina (myopia in that meridian). 

Symptoms of Astigmatism. — We may conclude that an indi- 
vidual is astigmatic if he sees horizontal (or vertical) lines, such as 
the horizontal portions of Roman capital letters, or the horizontal 
lines in music, or the horizontal rays in Snellen's Sunrise figure 
(see end of this book) distinctly, while the vertical (or horizontal) 




Fig. 26. 

lines seem indistinct. We have such a complaint, for example, 
when the retina is situated at the focus of the parallel rays passing 
through the vertical meridian of the cornea. 

Suppose an eye to be emmetropic in the vertical meridian, and 
ametropic in the horizontal meridian : we must first consider how 
a point will be seen by such an eye. The rays of light emitted 
from the point and passing through the horizontal meridian will 



Fig. 2.']. Fig. 28. 

not be brought to a focus on the retina, but will produce a blurring 
of the retinal image of the point at each side ; while the vertical 
rays will unite on the retina, and consequently the point will ap- 
j>ear distinctly defined above and below. 

A line may be regarded as a number of points, and in order to 
understand how lines will be seen by an astigmatic eye, such as 
the above, it is only necessary to arrange a number of points in 
vertical and horizontal lines — as at a and h in Fig. 2y. It is evident 



56 DISEASES OF THE EYE. 

at once from mere inspection that the horizontal line will appear 
distinct, because the rays which diverge from each point of the 
latter in a vertical plane — i. e., at right angles to the direction of 
the line — are brought to a focus on the retina ; while those rays di- 
verging in a horizontal plane, although not meeting on the retina, 
do not render the picture of the line indistinct, because the diffu- 
sion images resulting from them exist in the horizontal direction, 
and consequently cover or overlap each other on the line, and 
therefore are not seen and do not confuse the sight. At the ends 
of the line only {h, Fig. 28) do the diffusion images cause a fuzzi- 
ness or make the line seem longer than it is. In this case a ver- 
tical line {a, Figs. 27 and 28) seems indistinct, because, the hori- 
zontal meridian being out of focus, the diffusion images existing 
in that direction are very apparent, as they do not overlap. On 
the other hand, in order to see a vertical stripe accurately, it is 
necessary only that the rays diverging in a horizontal plane should 
have their focus on the retina ; and therefore if an individual can 
only see vertical lines distinctly at 6 meters we know that his eye 
is emmetropic in the horizontal meridian (and probably myopic in 
the vertical meridian). We do not, however, hear this complaint 
as often as might be expected, because simple astigmatism is not 
so common as one or other of the compound forms. 

Astigmatic people do not generally see very distinctly, either at 
long or at short distances. 

Even in hypermetropic astigmatism the book is very often 
brought close to the eyes, in order, by increasing the size of the 
retinal image, to make up for its indistinctness. 

Astigmatic individuals frequently suffer much from headache, 
due to constant effort to see distinctly, and we cure the headache 
when we correct the astigmatism. 

It has been stated that epilepsy, if not capable of being produced 
by refractive errors, especially astigmatism, in persons with stable 
brains, may sometimes have such errors as its exciting cause where 
there is already a predisposition to the disease. 

All these signs and symptoms appertain more to the rather high 
degrees of astigmatism. Slighter degrees may cause no annoy- 
ance beyond some indistinctness of vision ; and indeed slight de- 
grees of hypermetropic astigmatism often pass unnoticed until 
late in life, when the accommodation begins to fail. 

We are often led to suspect and to seek for astigmatism when, 
in examining the refraction with spherical glasses, we are able to 



ASTIGMATISM. 57 

bring about some improvement of vision, but cannot obtain normal 
V. with any glass, while there is no organic disease to account for 
the defect. Also if, in examining with spherical glasses, we find 
V. benefited equally by several glasses of considerable difference 
in power, even perhaps by convex as well as by concave glasses. 

The ophthalmoscope affords us an admirable means of diagnos- 
ing astigmatism and of determining its amount. Just as the astig- 
matic eye cannot see horizontal and vertical lines equally well at 
the same moment, so is an obsen^er unable to see both the vertical 
and horizontal vessels in the retina of the astigmatic eye simul- 
taneously, but must alter his accommodation to be able to see first 
one set of vessels and then the other. 

A comparison of the shape of the optic papilla, as seen in the 
upright and in the inverted images, may also give a clew to the 
presence of astigmatism. Inasmuch as the fundus oculi is very 
much magnified in the upright image by the dioptric media through 
which it is seen, and as this enlargement is greater in the direc- 
tion of the meridian of shortest focus (meridian of highest refrac- 
tion), which is most commonly the vertical meridian, a circular 
object, such as the papilla, will seem to be of an oval shape with 
its long axis vertical. But in the inverted image, in the meridian 
of highest refraction, the image lies nearer the convex lens than in 
the meridian of lowest refraction, and hence is much less magnified 
in the former than in the latter meridian ; and here, consequently, 
the round optic papilla is seen as an oval with its long axis hori- 
zontal. Sometimes the papilla is really of an oval shape, and 
not round, and then the diagnosis is readily made by observing 
that in one image it is seen as an oval, while in the other image it 
is circular. Care must be taken in the indirect method not to 
hold the lens obliquely, as this would be sufficient to make a cir- 
cular disc appear oval, the long axis of the oval being in the direc- 
tion of the axis round which the lens is rotated. 

The Estimation of the Degree of Astigmatism and its Cor- 
rection. — It is evident that to correct astigmatism the ordinary 
spherical lenses would be of little use, for they affect the refraction 
of the light passing through them equally in every direction. We 
employ therefore what are termed cylindrical lenses, being sec- 
tions of cylinders parallel to their axes, which refract light in one 
direction only — viz., that corresponding to their curvatures and 
at right angles to their axes. The rays which pass through these 
lenses in a direction corresponding to their axes are not refracted, 
5 



58 DISEASES OF THE EYE. 

but pass on without deAdation, as they would do through a piece 
of plane glass. 

Although astigmatism is nowadays almost universally esti- 
mated by means of the ophthalmoscope, or by the astigmometer 
(see p. 6i), yet in order to give the student a clear idea of the 
matter in the simplest way, I shall here describe a subjective 
method for its estimation, while its objective estimation by aid 
of the ophthalmoscope will be treated of in the next chapter. 

Simple Astigmatism. — If, novv^, a case come before us in which 
we suspect astigmatism, we place Snellen's Sunrise {vide diagram 
at end of book), or some such diagram, at 6 meters from the eye 
(the other eye being excluded), and inquire of the patient whether 
there be any line which he sees much more distinctly than the 
others, and can trace farther towards the central point. If that be 
so, we know that he is emmetropic in the meridian at right angles 
to that line, provided his accommodation be at rest, and that he is 
ametropic in the meridian corresponding to that line. 

In case the horizontal line below at each side be the distinct one, 
the eye is emmetropic in the vertical meridian, and probably 
hypermetropic in the horizontal meridian, because the latter is 
generally that of least curvature. Consequently, a convex cylin- 
drical lens, held with its curvature horizontally (axis vertical) be- 
fore the eye, will correct the defect. The highest convex cylin- 
drical glass which gives the patient the best possible distant vision 
will be the correcting glass. This would be a case of Simple 
Hypermetropic Astigmatism (As. H.). If the lens required be 
-f 2 D Cyl., it would be As. H. 2 D ; and in prescribing for the 
optician we should write '' + 2 D Cyl. Ax. Vert." 

If the central vertical line be the distinct one, then emmetropia 
exists in the horizontal meridian, and probably therefore myopia 
in the vertical meridian ; and a concave cylindrical lens held before 
the eye with its curvature vertical (axis horizontal) will correct 
the defect. The lowest concave cylindrical lens which gives the 
patient the best possible distant vision will be the correcting lens. 
This would be a case of Simple Myopic Astigmatism (As. M.). 
If the lens be — 2.5 Cyl., it would be As. M. 2.5 D; and for the 
optician we should write " — 2.5 D Cyl. Ax. Horiz." 

I advise the reader to make now a few experiments for himself 
with cylindrical lenses, by means of which he can produce artificial 
astigmatism in his own eye. Let him p4ace Snellen's Sunrise 
figure (end of this book) opposite his eye at a distance of about 4 



ASTIGMATISM. 59 

to 6 meters. If he now hold a + i.o Cyl. before his eye, with its 
axis horizontal, it gives a myopia of i.o D to the vertical meridian 
of the eye, while the horizontal meridian remains emmetropic ; and 
consequently he will see the central vertical line of the diagram dis- 
tinctly, while the horizontal lines will be indistinct. By placing 
a — 1.0 Cyl. with its axis vertical before the eye, in addition to the 
+ 1.0 Cyl., the artificial astigmatism produced by the latter is cor- 
rected, and the whole diagram becomes distinct. Every other kind 
and degree of astigmatism can be similarly represented by lenses 
and similarly corrected. 

Compound Astigmatism. — If no line be very distinctly seen, 
then we may commence our examination with Snellen's Distance 
Test-Types, and test in the ordinary way with spherical lenses 
until we find that one which gives the best distant vision. This we 
place in a spectacle-frame before the eye, and proceed, as already 
explained, to ascertain the meridians of greatest and least curva- 
ture of the cornea. If the spherical lens be -|- 4 D, and with it 

H.4D 



H. 4 D-f H. 



the horizontal lines in the Sunrise Diagram be the most distinct, 
then the vertical meridian is shown to be corrected, and the eye is 
probably still hypermetropic in the horizontal meridian, and re- 
quires a + cylindrical lens with its axis vertical, in addition to the 
spherical lens, to correct the entire defect. Suppose this cylin- 
drical lens be found to be + i D Cyl., then the H. in the hori- 
zontal meridian will be shown to be 5 D, and the astigmatism to 
be I D. 

The latter noted down would be of little practical value, and 
therefore we prefer to write in our note-books the factors of the 
Astigmatism, thus : '' H. 4 D + As. H. i D Horiz." ; or, as for the 
optician, '' -f 4 D Sph. C + i D Cyl. Ax. Vert." * This is Com- 
pound Hypermetropic Astigmatism. 

In an analogous way we examine for Compound Myopic Astig- 
matism, in which every meridian is myopic, but the vertical more 
so than the others. 

* The sign o indicates " combined with," 



6o DISEASES OF THE EYE. 

Mixed Astigmatism. — Lastly we come across cases in which 
both concave and convex spherical lenses produce a certain amount 
of improvement, but neither give full vision. Placing, then, one 
or other before the eye in the spectacle-frame, the examina- 
tion is proceeded with by aid of Snellen's Sunrise. We ascertain, 
for example, what is the lowest concave spherical lens which will 
bring out one horizontal ray distinctly. Let this be — 3 D; we 
have then myopia of 3 D in the vertical meridian. Now, having 
removed the — lens, we find what is the highest convex lens which 
will bring out one vertical line distinctly. Let it be -j- 5 D ; this 
indicates hypermetropia of that amount in the horizontal meridian. 
We may correct such a case in either of two ways : (a) by a Sph. 
— 3D, which will correct the vertical meridian, but will increase 
the hypermetropia in the horizontal meridian by 3 D, making it 
8 D, which can then be corrected by combining a cylindrical lens 
of -f 8 D, axis vertical, with the above spherical lens; (b) by a 
spherical + 5 D, which will correct the horizontal meridian, but 

M.3D 



H. D5 



will increase the myopia in the vertical meridian to 8 D, necessi- 
tating the combination of a — Cyl. lens of that number with the 
+ 5 D Sph. For reading, writing, etc., an overcorrection of the 
horizontal meridian with + 8 D Cyl., thus rendering the eye 
myopic 3 D in every meridian, and enabling the patient to read at, 
or near, his far point, might be the most suitable arrangement. 

As it is necessary, in order to test the degree, etc., of astigma- 
tism accurately, that the accommodation be at rest, it is desirable, 
before the examination for any of the hypermetropic forms, to 
instill atropin into the eye. 

Measurement of the Degree of Astigmatism by the Astig- 
mometer. — This is one of the most rapid and satisfactory methods 
of determining both the degree of astigmatism, and the position 
of the meridians of greatest and least refraction. It is based on 
the principle of the ophthalmometer, an instrument by which 
Helmholtz demonstrated the changes in the curvature of the lens 
during accommodation. 



ASTIGMATISM. 



6r 



The cornea reflects images of objects in the same manner as a 
convex mirror, and the smaller the radius of curvature the smaller 
will the image of any given object be. It is easy to calculate the 
radius of curvature of the cornea knov^ing the size of the object, 
the distance of the object from the cornea, and the size of the 




Fig. 29. 



cornea, and the size of the corneal image. The only difficulty lies 
in the measurement of this image ; and it has been found that the 
best method of effecting this is to double the image by looking at 
it through a double refracting prism, and then to alter the strength 
of the prism until the two images just come into contact. When 
this has taken place, a displacement equal to the size of the image 



62 DISEASES OF THE EYE. 

has been produced. The amount of displacement, and hence the 
size of the image, can easily be calculated. 

The astigmometer was first brought into practical use by Javal 
and Schiotz. The instrument which is in use at the Royal Victoria 
Eye and Ear Hospital, and which has proved of great service, is a 
modification of Javal's, made by Kagenaar of Utrecht. In order 




Fig. 30. 

to measure the degree of astigmatism by it, we do not require to 
know the radius of curvature of the cornea, but merely to find out 
the difference in refractive power between the meridians of greatest 
and least curvature, and this the astigmometer enables us to do in 
a few seconds without any calculation. 

It consists (Fig. 29) of a telescope {p) containing a double re- 
fracting prism between the object glasses, and two reflectors 
{k and /), which are movable on an arc {m) , which is fixed to the 
telescope tube. The latter turns on its own axis, and enables the 
arc to be placed in any meridian, its position being indicated on a 
graduated circle {g). The patient places his chin on the rest d, 
and looks into the tube at f, the eye which is not under observation 






Fig. 31. 

being covered by the disc e. The surgeon then looks through the 
telescope at ii, turns the arc m into a horizontal position, and ob- 
serves the corneal images of the reflectors, which he gets into 
focus. He then moves the reflectors until the central images just 
come into contact ; the four images will then occupy the relative 
positions shown in Fig. 30. The arc is then rotated into the ver- 



ASTIGMATISM 63 

tical meridian, and if the curvature of the cornea in this meridian 
be the same as in the horizontal meridian, the central images will 
still appear to be in contact ; but if the radius of curvature in the 
vertical meridian be smaller, the intervals a to ^ and a' to b' will 
diminish, and consequently the central images will overlap, as in 
Fig. 31, each step of a' representing a difference of i Dioptry. So 
that in this case (Fig. 31) there would be an astigmatism of 2 D, 
and the greatest refraction would be in the vertical meridian. 

It is generally desirable to begin with the arc in the horizontal 
meridian. If the axes of the meridians of greatest and least curva- 
ture are oblique, then the images will not lie in one line, and the 
arc must be turned until they do so lie. An index which moves 
on the circle g (Fig. 29) gives the position of the axes. It will 
be seen from the above description that the astigmometer merely 
registers the amount of astigmatism, but does not enable us to 
estimate the general refraction of the eye. Moreover, it is the 
corneal astigmatism alone which is determined, and it will be found 
that in the vast majority of cases this is the only astigmatism 
present. 

Lental Astigmatism. — Disturbances of vision due to astigma- 
tism often make their appearance for the first time at middle age 
or even later, and are then apt to be mistaken for amblyopia. In 
such cases the cornea has been astigmatic all through life, but the 
defect has been masked by a compensating astigmatism of the 
crystalline lens, produced by an unequal accommodative contrac- 
tion of the ciliary muscle. When, now, as life advances, the ampli- 
tude of accommodation diminishes, the power of the ciliary muscle 
to produce this active compensatory lental astigmatism also 
diminishes, and finally disappears, and consequently the corneal 
astigmatism comes to the front ; or, in astigmatic individuals the 
astigmatism may alter in degree at this time of life. Under atro- 
pin, too, astigmatism may appear, the existence of which was not 
previously known. This is termed active, or dynamic, lental 
astigmatism. 

Passive, or static, lental astigmatism is due to irregularity in the 
shape of the unaccommodated lens, and gives rise to disturbances 
of vision similar to those caused by corneal astigmatism, or it in- 
creases existing corneal astigmatism, or it more or less completely 
compensates the corneal astigmatism. It has no clinical importance 
which does not attach to corneal astigmatism. 



64 DISEASES OF THE EYE. 



Irregular Astigmatism. 

In irregular astigmatism, the refraction of the eye differs not 
only in different meridians of the eye, but even in different parts of 
one and the same meridian. It is frequently due to irregularities 
on the surface of the cornea, the result of former ulcers, and also 
sometimes to irregular refracting power in different parts of the 
crystalline lens. It cannot be corrected. Its presence can be de- 
tected by the distortion and irregular movement of the disc when 
the lens is moved during the indirect method of examining with 
the ophthalmoscope, and also by the irregular shadow in retino- 
scopy. In some cases there is a certain amount of regular astig- 
matism combined with it, correction of which may improve the 
vision. 

Anisometropia.* 

By this term is meant a difference in the refraction of the two 
eyes, one being myopic, hypermetropic, or astigmatic, while the 
other is emmetropic, or ametropic in a way different from its fel- 
low. So long as the difference in refraction is but slight (say i 
D or 1.5 D), it is generally possible to give the correcting glass to 
each eye. When the difference is considerable it is often impos- 
sible to fully correct each eye, because, binocular vision having 
never really existed, the patients are unable to tolerate the presence 
of a clear image on each retina. We must then be content with 
correction of the least ametropic eye, or of that one which has the 
best vision ; or we may partially correct the most ametropic, and 
fully correct the least ametropic eye. Each such case must be 
dealt with as it permits. 



ANOMALIES OF ACCOMMODATION. 

Presbyopia. 

This is a diminution in the amplitude of accommodation, which 
commences at an early age, and is due solely to natural changes 
taking place slowly in the crystalline lens. It might not, therefore, 
strictly speaking, be considered as an anomaly. The power of ac- 
commodation commences to diminish in early childhood, the near 

*a,priv.; loog, like; jutrpov, a measure. 



PRESBYOPIA. 



65 



point beginning then to recede from the eye. Bonders it was who 
first discovered this fact, and ascertained the laws which govern 
the progressive decrease of accommodative power. He designed 
the accompanying diagram (Fig. 32), which illustrates the de- 
crease from the tenth year of age, and indicates the amplitude of 
accommodation at different ages. 

The numbers along the upper horizontal Hne refer to the ages, 
those along the left-hand perpendicular line to the dioptrics. The 
curve r r shows the refraction of the eye when in a state of rest. 
This is unchanged until the fifty-fifth year, when it begins to 



f 


9 XT ^ ejr 30 Sff^ 40 4r SO ^^ <:^ es 70 rr « 
































49 


























_ 




\ 




























1Z 

11 


\ 






























V 




























V 


























() 






\^ 
























7 
6 
S 






\ 


y 




























\ 












( 
















\ 




























V 


S, 




























S 


V 












\ 1 


t 














\ 
















'■z 

i 
















X 






























S 


s^ 












i 




















X 


N^ 
























r 




^^ 


>V 


p 




. ? 
























o 


<^ 




-J 




























^"^ 




























' 


-/ 































Fig. 32. 

diminish ; the emmetropic eye then becoming hypermetropic, the 
hypermetropic eye more hypermetropic, and the myopic eye less 
myopic. The curve p p shows the positive refracting power of the 
eye, corresponding to the punctum proximum, and its gradual 
diminution as Hfe advances, and how at the age of sixty-five it be- 
comes even less than the minimum refraction in former years. 
The two curves meet at the age of seventy-three, and then all 
power of accommodation ceases. The number of dioptrics in- 
cluded between the two curves on the vertical line corresponding 
to any given age represents the amplitude of accommodation at 



^ DISEASES OF THE EYE. 

that age — e. g., at thirty years of age the ampHtude is 7 D ; at fifty 
years it is only 2.5 D. The ampHtude of accommodation is the 
same at the same age in all forms of ametropia, as well as in 
emmetropia. 

The cause of presbyopia lies chiefly in a progressive change in 
the crystalline lens, which becomes less elastic and more homo- 
geneous in its different layers, and refracts light less strongly than 
before. In more advanced life diminished energy of the ciliary 
muscle probably becomes a second factor in the production of 
presbyopia. 

The near point gradually recedes from the eye until it reaches a 
distance beyond that at which the person usually reads, writes, 
sews, etc. Employments of this kind then become difficult, be- 
cause the retinal images are too small to be clearly discerned, 
owing to the increased distance at which the work must be held 
from the eye ; and, in order to make up for this smallness of the 
images, the individual is often seen to improve their brilliancy by 
procuring stronger light. 

Presbyopia was defined by Bonders to be present when the near 
point lies at more than 22 cm. from the eye, and we correct it by 
giving such a convex glass for reading, etc., as will bring the near 
point back to 22 cm. Now in order to see at that distance a posi- 
tive refracting power (/') of (-^s^- =) 4.5 D is necessary, and 
if the eye have not so much positive refraction, a convex glass 
must be given to it of such power as will bring p up to 4.5 D ; and 
this lens is the measure of the presbyopia. At the age of forty 
{vide Bonders' diagram, Fig. 32) the eye possesses a positive re- 
fraction of just 4.5 B; and therefore from this age presbyopia 
{npaapvi, an old man ;&?'/-,) is said to commence in emmetropic 
eyes. The presbyopia, then, is equal to the difference between the 
positive refracting power possessed by the eye and 4.5 B, and the 
number thus found is' the correcting glass for the presbyopia. 
The distance of 22 cm. is rather close to the eyes for the com- 
fort of most people, and 33 cm. is now commonly taken as the 
reading distance. Presbyopia on this assumption is thus post- 
poned for two or three years. 

It is important that in prescribing glasses for presbyopia, if there 
be any hypermetropic astigmatism present, it should be corrected 
by the suitable + cylinder lens added to the spherical glasses. It 
is also important that the glasses should be carefully centered for 
the reading distance — i. e., that the visual lines, when they are con- 



PARALYSIS OF ACCOMMODATION. 



67 



verged to the distance at which the work is held, should pass 
through the optical centers of the glasses. Or, if there be any 
insufficiency of the internal recti, it will be for the patient's com- 
fort to decenter the lenses slightly inwards. 

The following table indicates the presbyopia of the emmetropic 
eye: 



Age. 


p. required. 


p. existing. 


Presbyopia. 


40 


4.5 


4-5 


0. 


45 


4-5 


3.5 


1.0 


50 


4.5 


2.5 


2.0 


55 


4-5 


1.5 


3.0 


60 


4.5 


0.5 


4.0 


65 


4.5 


0.25 


4.25 


70 


4.5 


-I.O 


5.5 


75 


4.5 


-1.75 


6.25 


80 


4.5 


-2.5 


7.0 



It is hardly necessary to point out that presbyopia comes on at 
a much earlier age in hypermetropes than in emmetropes ; while 
in myopes its advent is postponed ; or, in the higher degrees of 
myopia, it may not come on at all. The hypermetrope of 3 D would 
be presbyopic at the age of twenty-seven ; because, in order to 
arrive at the 4.5 D of positive refraction required, he must have an 
amplitude of accommodation of (3 D + 4.5 D) 7.5 D, and this he 
has only up to that age {vide Fig. 32). 

The myope of 4.5 D can get along until something over sixty 
years of age without any glass for reading {vide above table). At 
sixty-five, if he were emmetropic, he would have presbyopia of 
4.25 ; consequently he will now require a + glass of only 0.25 D. 

Presbyopia must not be mistaken for slight paralysis of accom- 
modation. They are distinguished by the fact that in the former 
the amplitude of accommodation corresponds to the age of the 
patient as given in Bonders' table, and the difficulty of near vision 
comes on gradually. 



Paralysis of Accommodation. 

This may be partial or complete, and one or both eyes may be 
affected. It is usually combined with paralysis of the sphincter 
iridis (mydriasis), and the condition is then called ophthalmo- 
plegia interna ; but it is also seen without paralysis of the sphinc- 



68 DISEASES OF THE EYE. 

ter, and either alone or with paralysis of some of the orbital muscles 
supplied by the third pair — rarely with paralysis of the external 
rectus. 

The Symptoms are similar to those of presbyopia, but come on 
rather suddenly. They give inconvenience to the patient accord- 
ing to the state of his refraction. If he be emmetropic, his dis- 
tant vision continues good, while his vision for near work is much 
impeded. If he be hypermetropic, as he requires his accommoda- 
tion for distant objects, vision for distance is interfered with, and 
still more so vision for near objects. If he be myopic, vision is less 
affected than in either of the other forms of refraction ; indeed, if 
he be very near-sighted, being able to see near objects at his far 
point, he may suffer little or no inconvenience. 

Micropsia is a common symptom in cases of partial paralysis of 
accommodation, and is due to the fact that, while the retinal image 
is unaltered in size, the great effort of the defective accommoda- 
tion gives the sensation of the object being much nearer to the eye 
than it really is. 

Causes. — The most common cause of paralysis of accommoda- 
tion is the action of atropin ; but it is also the result of, or is at- 
tendant upon, various diseases. It is one of the symptoms of 
paralysis of the third nerve ; it may be due to exposure to cold ; or 
it may depend upon syphilis, syphilitic periostitis at the sphenoidal 
fissure, syphilitic gumma, or syphilitic inflammation of the nerve 
itself. 

In cases of double paralysis of accommodation a central cause 
must often be looked for. Paralysis of accommodation and 
mydriasis are sometimes forerunners by many years of serious 
mental derangement. 

Diphtheria is a frequent cause of paralysis of accommodation, 
usually without, but sometimes with, mydriasis. The onset occurs 
most commonly some weeks after the throat affection, which need 
not have been of a severe character. Indeed, the faucial attack 
may have had no apparent diphtheritic character, and may have 
been so slight as almost to have escaped the notice of the patient. 
The lesion in these cases is probably a nuclear one, and the evi- 
dence points to miliary extravasations of blood in the floor of the 
fourth ventricle ; but there are those who hold that the paralysis is 
due to a poison, that it is a toxic paralysis. 

In influenza paralysis of accommodation is seen, occurring some- 
times in the acute stage and sometimes during convalescence. 



PRESBYOPIA. 69 

One recorded case went on to bulbar paralysis, and ended fatally ; 
but complete recovery is usual. 

Paralysis of accommodation in middle life may be due to dia- 
betes, and should make us suspicious of the presence of this 
disease. 

Blows on the eye are apt to cause paralysis of accommodation, 
usually with mydriasis. 

The Treatment depends, of course, upon the cause of the paral- 
ysis. The instillation of a i per cent, solution of sulphate of 
eserin or of muriate of pilocarpin may be employed in all cases, 
and will at least produce temporary improvement of sight ; but it 
can hardly be said to assist in the cure, except perhaps in slight 
diphtherial cases. lodid of potassium and mercury are indicated 
in syphilitic cases, and iodid of potassium and salicylate of sodium 
in rheumatic cases. The prognosis in these cases must be very 
guarded, as it often happens that recovery does not take place. 
Where cure does not result the patient may be enabled to make 
better use of his eye or eyes by means of a convex glass or spec- 
tacles ; but in this matter each case must be dealt with for itself — 
no general rule can be laid down. 

In diphtheritic cases a general tonic treatment, especially iron, 
is indicated ; and here the prognosis is invariably favorable. 

Accommodative Asthenopia 

has been already treated of under the head of Hypermetropia 
(p. 40). 

Spasm of Accommodation. 

Spasm, or cramp, of accommodation in connection with hyper- 
metropia and myopia has already been referred to. A few cases 
of acute spasm of accommodation have been reported.* Occur- 
ring in an emmetropic or slightly hypermetropic eye, such a spasm 
produces apparent myopia. In some of the cases there was no 
assignable cause for the spasm, in some it was due to overwork, 
and in one to trauma of the cornea. The treatment is a length- 
ened course of atropin locall}*.. 

References. 

* " Trans. Internat. Ophth. Congress," 1888, p. 97. 
^ " Von Graefe's Archiv," xxxvi. 2, p. i. 
^ " Zeitschrift fiir Augenheilkunde," vol. v. p. 171. 
* " Von Graefe's Archiv," xxxvi. p. 232. 



CHAPTER III. 

THE OPHTHALMOSCOPE. 

Although the dioptric media of an eye may be perfectly clear 
and normal, yet no detail of its fundus can be discerned by the un- 
aided eye of an observer who looks through the pupil, the latter 
being for him merely a dark opening. The reason of this is that 
these dioptric media are composed of a system of convex lenses. 
To explain : Suppose the inside of a small box (7/ide Fig. 33) to be 
blackened, and on its floor some printed letters fastened, and a 
hole cut in the lid, which is then replaced — it will be found that, 
by aid of a lighted candle and with a little experimentation, the 
letters may be read through the aperture. The rays passing from 
the light (L) into the box through the aperture illuminate the 




Fig. 33. 

opposite surface, and from this surface the rays a, h, and others 
pass out again through the opening, and some of them fall into the 
observer's eye at E. 

But if, in order to make this box represent an eye more accu- 
rately, we place a convex lens immediately within the aperture, the 
course of the rays is altered. All the rays passing into the box 
(Fig. 34) from L are brought to a focus on its opposite side at 
rn by the convex lens 11, and according to the optical law of con- 
jugate foci, all the rays passing out from the box meet again at 
the source of light (L), and hence none of them can be received 
by the eye (a) of the observer; nor can this eye be placed in any 

70 



THE OPHTHALMOSCOPE. 



71 



position where it could catch any of these rays, for if it be placed 
anywhere between the aperture and L, it would cut off the light 
passing from L into the box. 

Helmholtz's Ophthalmoscope. — If the eye of the observer could 
itself be made the source of light, the difficulty would be solved ; 




Fig. 34. 

and, practically, this is what Helmholtz accomplished with his 
ophthalmoscope in the year 1851. The instrument he invented 
was composed of a number of small plates of glass (0, Fig. 35), 
from which light from L was reflected into the eye (£), and thus 
the fundus of the latter illuminated. From m rays pass back again 
by the same course to the ophthalmoscope, some being reflected 
back to L; but some, passing through the ophthalmoscope, and 
falling into the observer's eye placed close behind the instrument 
at a, form in it an image of m. 

Modern Ophthalmoscope. — For the original ophthalmoscope of 
Helmholtz a concave mirror of 20 cm. focal length with a central 



Fig. 35. 

opening has been substituted. This mirror {O, Fig. 36) throws 
convergent rays into the eye (£) ; and these, being made more 
convergent by the refracting media, cross in the vitreous humor, 
and light up part (a h) of the fundus. From every point of this 
illuminated surface rays are reflected back again out of the eye. 



72 DISEASES OF THE EYE. 

If the latter be emmetropic the rays from any one pomt become 
parallel on leaving it ; and some of these parallel rays, passing 
through the aperture (c) oi the ophthalmoscope, fall into the ob- 
server's eye, and, if it be emmetropic, are brought to a focus on its 
retina ; the rays from m at m', those from x at x', and those from 
y at y' — and thus an image of the part x m y is formed on the ob- 
server's retina. 

The foregoing method of examining with the ophthalmoscope 
is called the Direct Method, or the Examination of the 
Upright Image. By it the various parts of the fundus are seen 
in their natural positions, but much enlarged (about 15 diameters 
in the emmetropic eye) ; and it is consequently very valuable for 
examining minute details. 

It is necessary for this method that the surgeon should approach 




Fig. 36. 

his eye as close as possible to the eye under examination, in order 
to receive as much of the light coming out of it as possible. 

It is also necessary for this method that the accommodation both 
of the surgeon's and of the patient's eye be at rest, as otherwise 
the rays coming from the latter cannot form an image on the 
retina of the former, at least if both be emmetropic. 

If the patient exert his accommodation, the rays will, on leaving 
his eye, become convergent instead of parallel, and, falling into 
the surgeon's eye, will be brought to a focus in front of his retina. 
If the surgeon exert his accommodation, the parallel rays from the 
patient's eye will likewise, on falling into his (the surgeon's) eye. 
be brought to a focus in front of his retina. And if both patient 
and surgeon accommodate, the focus of the rays from the patient's 
fundus oculi will, of course, lie still farther in front of the sur- 
geon's retina. The patient's accommodation can be relaxed by 



THE OPHTHALMOSCOPE. 73 

making him gaze at the black wall behind the surgeon's head, or 
his accommodation may be paralyzed with atropin. But atropin 
should never be used unless absolutely necessary, owing to the in- 
convenience it causes the patient. 

Voluntary relaxation of the accommodation on the part of the 
surgeon is often a matter of much difficulty to beginners. The 
ciliary muscle not being a voluntary muscle is not under our direct 
control, and can be influenced only in a secondary way through the 
convergence of the optic axes ; for this convergence is regulated 
by voluntary muscles (the internal and external recti), and is inti- 
mately associated with the effort of accommodation. With paral- 
lel optic axes our accommodation is relaxed ; therefore, when we 
want to relax our accommodation, we produce parallelism of our 
optic axes. This sounds easy enough ; yet, when the beginner 
approaches his eye close up to that of his patient, the knowledge 




Fig. zt. 

that he is so close to the object he wishes to see renders the accom- 
plishment of this parallelism and relaxation of accommodation 
very difficult to many. 

It is not easy to teach another person how to relax his accom- 
modation, but the following hint may be of use. Take a printed 
page, and hold it at the ordinary reading distance, so that the type 
may be clearly seen ; then gaze vacantly at it, so that the type may 
become indistinct. The accommodation is now relaxed, and the 
act is accompanied by a peculiar sensation in the eyes. When 
examining in the erect image, cause this same sensation to take 
place ; and it may be assisted if, with the eye which is not in use, 
the black wall behind the patient's head be gazed at. 

The Indirect Method, or the Examination of the Inverted 
Image, is employed in order to obtain a more general view of the 
fundus than the direct method admits of. 



74 DISEASES OF THE EYE. 

In addition to the ophthalmoscope a convex glass (/, Fig. 37) 
of about 14 D is here used. The latter is held about 10 cm. from 
the eye (E) under examination, while the observer throws the 
light through it into the eye. In passing through the lens the rays 
are made convergent, and this convergence is increased by the re- 
fracting media, so that the rays cross in the vitreous humor, and 
light up a portion of the fundus oculi. From any points (a and b) 
of this illuminated place pencils of rays pass out again from the eye, 
and, becoming parallel, pass through the lens, and are united by it 
at a' h' ; and thus a real inverted image is formed of the part a b, 
which image may be seen by the observer whose eye is placed be- 
hind O. The stronger the lens (/) the more convergent must 
rays from the examined eye be made ; and consequently the closer 
must a' b' be to each other, and the smaller and brighter must be 




Fig. 38. 

the image formed. The weaker the lens (/) the larger and less 
brilliant is the image, and the less annoying to the surgeon are the 
reflexes from the surfaces of the lens. 

In examining by the indirect method the observer first places 
the upper edge of the ophthalmoscope to his right supra-orbital 
margin, and, taking care that he is looking through the central 
opening of the mirror, he reflects the light of the lamp into the 
patient's eye at a distance of about 50 cm. A red glare from the 
fundus will then be seen in the pupil. Keeping the pupil illumi- 
nated, the convex 14 D, held between the forefinger and thumb of 
the surgeon's left hand, is brought up in front of the patient's eye, 
and kept there in the perpendicular position, the surgeon steadying 
this hand with the tip of the little finger on the patient's forehead. 
The convex glass is now removed just far enough from the pa- 
tient's eye to cause the margin of the pupil to disappear out of the 



THE OPHTHALMOSCOPE. 75 

surgeon's field of vision. The observer then ceases to look into 
the eye, and fixes his gaze on the convex glass, when the inverted 
image of the fundus should at once become visible — and will seem 
to be situated in the convex lens, although it really is in the air 
somewhat this side of the lens. 

The diagram (Fig. 38) serves to illustrate the effect of inver- 
sion of the image. 

The left eye is seen in the upright image in the left-hand picture, 
while the same is seen in the inverted image in the right-hand 
picture. In the diagram the two images are of the same size for 
the sake of convenience ; although, of course, in reality the upright 
image is much larger than the inverted image. Moreover, it 
should not be supposed that nearly the whole fundus oculi, as here 
represented, can be taken in at one view with the ophthalmoscope. 
The portion visible with the ophthalmoscope at one moment, even 
in the inverted image, is small ; so that it is necessary to examine 
the different regions in detail in order to become acquainted with 
their condition. 

The reflex from the surface of the cornea gives a good deal of 
annoyance to every beginner. It cannot be done away with ; but 
as it moves in the opposite direction to a motion of the object lens 
it is possible to see past it. The reflections from the convex object- 
lens are also extremely annoying, but may be removed to a great 
extent from the line of sight by a slight rotation of the lens on its 
axis. If a very high convex lens (say -j- 20 D) be used, the re- 
flections from it are more disturbing than from a lower number 
(say+i4D). 

To examine the Optic Nerve the surgeon sits in front of the pa- 
tient, and directs him to turn his eye somewhat to the nasal side, 
and slightly upwards ; because the papilla, or disc, is situated about 
15° to the inner side of the posterior pole of the eye, and about 3° 
above it. For instance, if the left eye be examined the patient is 
to direct his gaze, without turning his head, to the right and a 
little upwards, say towards the surgeon's left ear. It is well always 
to seek out the optic papilla in the first instance, not only because 
it is so important a part of the fundus oculi, but also because, ex- 
amining from it towards the periphery, we are the better able to 
determine the locality of any pathological alteration. 

Should the patient not direct his gaze in such a way as to enable 
the surgeon to see the optic disc or other desired region, it may 
be brought into view either by a motion of the surgeon's head in 



76 DISEASES OF THE EYE 

the opposite direction, or by a motion of the convex lens in the 
same direction, or by a combination of both these maneuvers. 

The Macula Lute a should then be examined. It may be seen 
by directing the patient to look straight at the hole of the ophthal- 
moscopic mirror, for it will then correspond with the macula lutea 
of the observer's eye. It is more readily seen in the inverted than 
in the upright image ; but its examination is often very difficult, 
owing to contraction of the pupil produced by the strong light fall- 
ing on so sensitive a portion of the retina, and by the reflections 
from the surfaces of the cornea and crystalline lens, which fill the 
area of this contracted pupil. It is therefore a better plan to direct 
the patient to look somewhat to the side of the eye under examina- 
tion — e. g., to the right side of the observer's forehead, if the left 
eye be under examination, and then by motions of the convex lens 
to bring the macula lutea into view. 

After this the Periphery of the Fundus in every direction is to be 
examined by making the patient look upwards, downwards, to the 
right, to the left, etc. 

Estimation of the Refraction by Aid of the 
Ophthalmoscope. 

From what has been said with reference to the Direct Method 
of ophthalmoscope examination, it will have become evident that 
this method affords a means for determining the refraction of the 
eye. 

At a little distance from the observed eye into which light from 
the ophthalmoscope mirror is thrown, the surgeon will be able to 
make the qualitative diagnosis of the refraction. If he can see 
some of the details of the fundus, it is either myopia or hyper- 
metropia ; but if it be emmetropia, he will be unable to see any de- 
tail. The explanation of this is that in myopia the rays coming out 
of the eye form an inverted image at the far point of the eye in 
the air, and this image can be seen by the observer who accommo- 
dates his eye for that point. In hypermetropia the rays coming 
out divergently from the eye pass into the observer's eye, and by 
an effort of accommodation on his part he will see an upright image 
of the portion of the patient's fundus oculi from which they come. 
But in emmetropia, inasmuch as the rays come out parallel, those 
from any two points {m n, Fig. 39) at a short distance from each 
other in the fundus on emerging from the eye diverge quickly from 



THE OPHTHALMOSCOPE. ^^ 

each other, and the observer a little way off (at ^) receives none 
of them into his eyes, or obtains only an indistinct image or red 
glare. If he go very close to the eye he can see details. 

If on the observer moving his head from side to side the vessels, 
etc., of the observed fundus move with him, the case is one of 
hypermetropia, because the image is an erect one, which is situated 
behind the plane of the pupil to which it is referred. If the vessels, 
etc., move in the opposite direction to that of the observer's head, 
the observed eye is myopic, because there the image is inverted 
and in front of the pupil. 

For the quantitative determination of ametropia a refraction 
ophthalmoscope is required. This instrument provides a number 
of convex and concave lenses capable of being brought into posi- 




FiG. 39. 

tion behind the sight-hole in rapid succession by a simple mechan- 
ism, and the direct method (p. y2) is employed. 

It is necessary, in the first instances, that the surgeon be ac- 
quainted with the nature of his own refraction. 

// the Surgeon he Emmetropic he can see the fundus oculi of an 
emmetrope in the upright image without any lens, provided he go 
close enough, as the parallel rays coming from the examined eye 
will be focused on his retina, because his eye is adapted for parallel 
rays. 

In order to see the fundus oculi of a hypermetrope without any 
effort of accommodation he must place such a convex lens behind 
his ophthalmoscope as will render the divergent rays coming from 
the patient's eye parallel before they pass into his eye. This lens 
is the measure of the patient's hypermetropia, because it shows 
how many dioptrics the eye wants of being emmetropic; or, in 



78 DISEASES OF THE EYE. 

other words, so that the rays coming from it may be made parallel. 
The lens which makes the divergent rays coming from the pa- 
tient's retina parallel would also give to parallel rays passing into 
the eye such convergence that they would meet on the retina — 
i. e., it would correct the hypermetropia. 

The emmetropic surgeon can of course see the fundus oculi of 
a hypermetrope by the direct method without the correcting glass 
if he use his accommodation to overcome the divergence of the 
rays, and this is usually the case in the lower degrees of hyper- 
metropia. The surgeon generally relaxes his accommodation ac- 
cording as he substitutes convex lenses for it, until he reaches the 
strongest lens with which he can distinctly see the fundus. This 
is the correcting lens. 

To see the fundus oculi of a myope the emmetropic surgeon 
must place a concave glass behind his ophthalmoscope, in order 
that the convergent rays coming from the observed eye may be 
made parallel before they pass into his eye; and the lowest con- 
cave lens which enables him to see the fundus oculi is the measure 
of the myopia, as showing by how many dioptrics it is in excess of 
emmetropia. 

The emmetropic surgeon cannot possibly see the fundus oculi 
of a myope without the correcting glass, as the rays are brought 
to a focus in front of his retina, and if he use his accommodation 
he merely makes them still more convergent. But by means of an 
effort of his accommodation he can see the myopic fundus with a 
lens which overcorrects the myopia, and hence the importance of 
selecting the weakest concave glass with which the fundus is dis- 
tinctly seen. 

If the surgeon be ametropic, he may either correct his ametropia 
by wearing the suitable lens, and then proceed as though he were 
emmetropic, or else, and which is perhaps the better plan, he may 
add or subtract the amount of his ametropia from that of his pa- 
tient's. For example : 

The Hypermetropic Surgeon of say 3 D requires a + lens of 
3 D in order to see an emmetropic fundus oculi, this lens going 
altogether to correct his own defect. If in order to examine the 
fundus of another eye he require a + lens of 6 D, the examined 
eye must be hypermetropic 3 D, the other 3 D going to correct the 
surgeon's H. If he be able to see the fundus oculi under observa- 
tion without any lens, it shows that the eye has an excess of re- 
fraction corresponding to the want of refraction in his own eye — 



I 



THE OPHTHALMOSCOPE. 79 

that is to say, it is myopic 3 D. If he require a concave 2 D, his 
want of refraction — his hypermetropia — is not enough by that 
number of dioptrics, and he has to do with an eye which is myopic 
5D(3D + 2D). Again, if he can see the fundus distinctly 
with a + lens, say + i-O, which is less than his own correcting 
glass, this shows that the eye he is examining is myopic, but my- 
opic to a lesser degree — in this instance by i D — than he himself 
is hypermetropic, and the examined eye here would be M. 2.0 D 
(i. ^.,3.0—1.0). 

// the Surgeon be Myopic say 2 D, he requires a — 2 D to see 
the fundus of an emmetropic eye, this lens going wholly to correct 
his own ametropia. If he see the fundus with a — 7 D> the ex- 
amined eye has M. 5 D, because 2 D has been used in correcting 
the surgeon's M. If he be able to see a fundus without any lens, 
the patient has H. 2 D, the want of refraction in the latter's eye 
compensating exactly for the excess of refraction in the surgeon's 
eye. If he finds it necessary to use a + lens of 7 D, it will indi- 
cate that his excess of refraction is not able to make up for the 
defect of refraction in his patient's eye, and that the latter has H. 
= 9 D (2 D + 7 D). If he have to use a — lens, say — i.o D, 
which is less than his own correcting glass, this shows that the 
eye he is examining is hypermetropic to a lesser degree — in this 
instance by i.o D — than he himself is myopic, and the hyperme- 
tropia here would be 1.0 D (/. e.^ 2.0 — 1.0). 

The Existence and Degree of Astigniatism may be Determined 
with the Ophthalmoscope. — We know that astigmatism is present 
if in the upright image we see the upper and lower margins 
of the disc and the horizontal vessels well defined, while the 
lateral margins and the vertical vessels are blurred, or znce versa. 
Again, we know that astigmatism is present if in comparing the 
shape of the optic disc in the upright and inverted images we 
find it to be an oval with its long axis perpendicular in the former, 
and with its long axis horizontal in the latter, showing that the 
refracting media are more powerful in the vertical than in the 
horizontal meridian. 

We may ascertain the kind and degree of astigmatism as fol- 
lows: 

If in the upright image with relaxed accommodation we can see 
the retinal vessels in one meridian distinctly, while in order to 
see those in the opposite meridian a concave or convex lens behind 
the ophthalmoscope is required, we know that the case is one of 



8o DISEASES OF THE EYE. 

simple myopic or hypermetropic astigmatism ; the emmetropic 
meridian being that at right angles to the vessels* seen without 
any lens, and the number of the lens indicating the amount of 
ametropia in the other meridian. 

If in the two principal meridians two concave lenses or two 
convex lenses of different strength be required, we have to deal 
with a case of compound astigmatism, myopic or hypermetropic; 
the greatest error of refraction being in the meridian at right 
angles to that one, the vessels of which are made distinct by the 
strongest lens. 

If a concave lens be required to bring into distinct view the 
vessels in one meridian, while a convex lens is required for the 
opposite meridian, the case is one of mixed astigmatism. Myopia 
exists in the meridian at right angles to that in which the vessels 
are brought into view by the concave lens, and hypermetropia ex- 
ists in the opposite meridian. 

I would again impress upon the reader the absolute necessity 
of thoroughly relaxing his accommodation in all examinations 
in the upright image. 

Retinoscopy. 

Another and most useful method for determining the refrac- 
tion by the ophthalmoscope is termed the Shadow Test, or Retino- 
scopy. The appearances upon which this method depends are due 
to the play of light reflected from the mirror on the fundus oculi. 
Either a concave or a plane ophthalmoscopic mirror may be em- 
ployed. 

Retinoscopy vvrith the Concave Mirror. — If the rays from a 
light (L, Fig. 40) be reflected from the concave mirror (m) of an 
ophthalmoscope, they cross at a certain point (A), and form there 
an inverted image of the flame, and then diverge again. If these 
diverging rays be made to pass through a convex lens (B) placed 
at such a distance in front of a screen (E) that the rays meet at a 
focus on the latter, a very small and brilliant upright image (0) 
of the flame is there formed, surrounded by a deep shadow. If 
the screen be moved slightly towards the lens (to H), so that the 
focus of the rays would lie behind it, or if it be removed slightly 
away from the lens (to M), so that the focus come to lie in front 

* The vessels may be regarded as lines, and the explanation given on 
pp. 55 and 56 applies to them also. 



RETINOSCOPY. 8i 

of it, the brilliancy of the image on the screen and the intensity of 
the surrounding shadow are reduced ; because in each instance a 
circle of diffusion, and not an accurate image, is formed on the 
screen, and the farther the focus of the pencil of rays is situated 
from the screen in either direction the weaker does the image be- 
come and the more ill-defined the shadow. 

If the mirror be rotated in various directions the illuminated 
part* and the shadow are seen (care being taken to look at the 
screen directly, and not through the lens) to move on the screen 
in the opposite direction to the motion of the mirror. For example, 
if the position iii (Fig. 40) be given to the mirror, the path of 




Fig. 40. 

the rays reflected from it is shown by the dotted lines, and the im- 
age of O is moved to 0'. This will also be the case if the screen 
be at // or at M. Now these three positions of the screen may be 

* " The area of light," " the image,'' " the illuminated area, or part of 
the fundus," and " the illumination '' are different terms for one and the 
same thing. " The shadow " or " shade " refers merely to the margin of 
the illuminated area — i. e., where the illumination ceases and darkness 
begins; it does not mean that the shadow of any object is thrown on 
the fundus oculi. When we speak of the motion of the shadow we mean 
that the margin of the illuminated area, or boundary-line between illu- 
minated and non-illuminated area, moves along with the illuminated 
area in response to the motion of the mirror. It is easier to see how the 
illuminated area moves by watching the margin of the shadow (which 
comes across the pupil from behind the iris like a revolving shutter across 
a shop window), and hence it is that we have come to talk always of the 
motion of the shadow and not of the motion of the illuminated part. 

7 



82 DISEASES OF THE EYE. 

supposed to represent emmetropia (£), hypermetropia (H), and 
myopia (M). Fig. 40 more particularly illustrates the motion of 
the light and shade in E and H only, while Fig. 41 demonstrates 
that in M. 

In the eye, in like manner, the area of light and shade in the 
pupil moves against the motion of the mirror. Now we cannot, 
of course, see the real motion on the retina directly, but only 
through the dioptric media, and they will influence the apparent 
motion according to the condition of the refraction. 

In emmetropia and in hypermetropia the rays coming out of the 
observed eye are parallel and divergent respectively; and, conse- 




FiG. 41. 

quently, an upright image being formed by them in the observer's 
eye, the true motion given by the mirror is perceived. 

In myopia, at least in all cases of more than i D, the observer 
does not see an upright image of the flame on the fundus of the 
observed eye, but a real inverted aerial image formed between his 
mirror and the observed eye. The reason of this is that the rays 
coming out of the patient's eye are convergent, and meet at a 
focus, which is the far point of the eye, and form there an inverted 
image of the object from which they come, and which, in this 
instance, is an upright image of the flame (the illuminated area). 
When, therefore, the upright image on the fundus moves against 
the mirror, the inverted image (which the observer sees) moves 
in the opposite direction — i e., with the mirror. For example, if 
in Fig. 41 we suppose a to be the position of the image on the 



RETINOSCOPY. 



83 



fundus of a myopic eye, and a'- the position of its real inverted 
aerial image, a motion of the mirror to m' (the rays reflected from 
m' are omitted in order to avoid confusion in the diagram) throws 
the image of a to a', as already explained, but the inverted aerial 




Fig. 42. 

image of a' is formed at a" — i. e., it seems to have moved with the 
mirror. 

In myopia alone, then, does the image move with the mirror; 
while in emmetropia and hypermetropia it moves against the 
mirror. In low myopia (i D and less), as will just now be seen, 
the image also moves against the mirror. 

From what has been said it is evident that the higher the ame- 
tropia (the farther from the screen, in Fig. 40, the focus of the 
rays) the larger and feebler the illumination becomes (i. e., the 




Fig. 43. 



greater the circles of diffusion), and the more crescentic the 
margin of the shadow, because it is the margin of a circle of dif- 
fusion. 

Again, the extent of the motion of the image and the rate of 
this motion are in inverse proportion to the degree of the ame- 



84 DISEASES OF THE EYE. 

tropia. Thus, if Fig. 42 represents a myopic eye, whose far point 
is situated at a-, a motion of the mirror to w' may be supposed 
to throw the ilkiminated part to a', and then oj^ will move to a'. 
But if the myopia be of less degree, so that the far point is at a^, 
the same motion of the mirror will throiw a? to o! , and the distance 
between these two latter points is evidently much greater than 
that between a^ and a-'. In a hypermetropic eye (Fig. 43), the im- 
age may be supposed to be formed at a, and a motion of the mirror 
to m' will throw it to a' ; while in a lower degree of hypermetropia 
it would be formed at h, and the same motion of the mirror would 
throw it to h'. The distance between h and h' is much greater 
than that between a and a\ 

In practicing retinoscopy with the concave mirror the surgeon 
sits 1.20 m. in front of the patient. The eye to be examined is 
shaded from the direct rays of the lamp, if the latter be placed 
beside the patient ; but a better plan is to have the light above his 
head. The focus of the mirror should be 22 cm., and any error 
of refraction of the surgeon is to be corrected. The light is then 
throv/n into the eye at an angle of about 15° with its axis of vision, 
so that if the pupil be not under the influence of atropin the 
macula lutea may be avoided. When now the ophthalmoscope is 
rotated in different directions, motions of the light and shade on 
the fundus oculi are seen in the pupillary area. The surgeon di- 
rects his attention to the edge of the shadow rather than to the 
illuminated part, for its motion is more easily appreciated. If the 
edge of the shadow move with the motion of the mirror, myopia 
is present ; if it move against the mirror, emmetropia, hypermetro- 
pia, or myopia of only i D or less is present. 

The reason why the motion is against the mirror in cases of 
M. 1 D and less is that the surgeon being seated only 1.20 m. from 
the eye he is examining, if that eye have a myopia of i D, its far 
point is so close to his eye that he cannot clearly observe the image 
there formed ; but if the myopia be of even slighter degree, the im- 
age will be formed behind the surgeon's head, and he gets a 
shadow moving against the motion of his mirror, because the im- 
age he then sees is the upright one of the patient's fundus oculi, 
and not the inverted aerial image. 

We proceed as follows : 

A trial spectacle-frame is put on the patient's face. If the 
shadow move with the mirror, we know at once the eye is myopic. 
To find the degree of myopia the surgeon puts a low concave-glass 



RETINOSCOPY. 85 

(say — I D) into the frame; and if the shadow still move with 
the mirror, he puts in a higher number (say — 1.5 D), and so on 
until he comes to a glass which makes the image move against the 
mirror. If this be — 3D, the myopia is 3 D. It might be sup- 
posed, as the shadow now moves against the mirror, that this 
glass overcorrects the myopia ; but this is not so, because, as al- 
ready explained, when the myopia is very low the image is formed 
close to the surgeon's eye, or behind his head, and he consequently 
gets a shadow moving against the mirror, although low myopia, 
and not emmetropia, is present. Consequently — 0.5 D, or — i 
D, has to be added on to the lens, which gives the effect of no 
distinct shadow ; or rather, by the above plan, it is not deducted 
from the lowest lens, which makes the shadow move against the 
mirror. 

If the shadow move against the mirror, we have to determine 
whether the eye is emmetropic, hypermetropic, or slightly myopic. 
Should the illumination be bright, and the shadow well defined, 
the eye is emmetropic, or not far removed from it ; and if the 
shadow be ill defined and crescentic, we may feel sure the eye is 
highly hypermetropic. We first put on -|- i D> ^^d if the motion 
be still against the mirror, the case is one of hypermetropia, and 
higher numbers are at once proceeded with until that one is 
reached which causes the shadow to move with the mirror. The 
measure of the hypermetropia is i D less than the glass so found, 
for it has evidently overcorrected the defect. 

If, however, en putting on + i D we find the shadow to move 
with the mirror, we change it for + 0.5 D ; and if still the motion 
be with the mirror, the eye is, beyond doubt, slightly myopic, 
— 0.5 D or so. But if with -f- i D the shadow move with the 
mirror, while with + 0.5 it continue to move against it, the eye is 
emmetropic. 

It may be found that in two opposite meridians there is a 
difference in the motion of the shadow, and this leads us to diag- 
nose the presence of astigmatism. When the difference is one 
merely of rapidity of motion, or of intensity of illumination 
and shadow, we know that we have to do with either simple 
or compound astigmatism. But if in the two meridians there be a 
difference in the direction of the motion, then it is a case of mixed 
astigmatism. The best method for ascertaining the degree of as- 
tigmatism and its correcting glass is to correct each of the prin- 
cipal meridians separately with spherical lenses. In compound 



86 DISEASES OF THE EYE. 

astigmatism the difference between the two lenses found indicates 
the degree of astigmatism and also the cylindrical lens which, com- 
bined with the correcting spherical lens for the least ametropic 
meridian, is required to neutralize the defect. In mixed astig- 
matism the addition of the two numbers gives the cylindrical lens, 
while one or other of them, usually the + D, is used as the spheri- 
cal lens. 

Retinoscopy with the Plane Mirror. — With the plane mirror 
the source of illumination of the observed eye is not a real in- 
verted image of the light, as in the case of the concave mirror, 
but a virtual upright image behind the mirror ; and as this image 
moves in the opposite direction to the motion of the mirror, the mo- 
tion of its illumination on the fundus of the patient's eye must 
be with the mirror in all cases, and not against it, as in using the 
concave mirror. 

With the plane mirror, therefore, the shadow is seen to move 
with the motion of the mirror in H. and E. ; but in M. it seems 
to move against the motion of the mirror, for what we here see 
is an inverted image of the fundus situated at the far point of 
the eye. If the myopia be high, this inverted image will be close 
to the eye ; if low, it will be far away from it. In using the plane 
mirror it is important to remember this point, because, if the ob- 
server go nearer to a myopic eye than its far point, he will not ob- 
tain a myopic motion, but one which is the same as that in E. or H. 
Consequently, in using the plane mirror, the rule is to go as far 
from the eye under examination as possible. If at the beginning 
the surgeon retire a little more than 2 meters from the eye, and 
there obtain a with-motion, he at once knows that the eye is not 
myopic 0.5 D ; or if he stand a little more than 4 meters away, and 
obtain the same motion, he knows there is not a myopia of even 
0.25 D present. If the myopia be high, he will be able to begin 
close to the patient, but must gradually retire from the eye as he 
increases the number of the concave glass put up — for the far 
point is thereby moved farther off — in order that he may not 
think he has corrected the myopia before he really has done so. 
Again, if at every distance the motion be with the mirror, the 
surgeon has to decide whether this indicates E. or H. He does 
this by putting a low + lens (say + 0.25) before the patient's 
eye, and if then, standing at a distance of 4 meters, the motion 
be altered by this glass to one against the mirror, he knows that 
the eye has not a hypermetropia of 0.25 D, consequently that it is 



FOCAL OR OBLIQUE ILLUMINATION. 87 

emmetropic. But if this lens does not at that distance cause a 
change in the motion of the shadow as originally obtained, the eye 
must be hypermetropic to at least the extent of 0.25 D; and, in 
order to ascertain how much more of H. than this may be present, 
it is now only necessary to go on increasing the strength of the 
lens in front of the patient's eye until one is reached which at 
4 meters from the eye produces the myopic motion. The ob- 
server knows that he has now slightly overcorrected the hy- 
permetropia of the eye, and that the next lens lower is its 
measure. 

With some practice it is possible, unless the pupil be small, to 
obtain sufficient light from the fundus with the plane mirror at a 
distance of 4 meters. 

I find this method much more easily worked than that with 
the concave mirror. It has the advantage, too, of not requiring 
any wearisome addition to, or subtraction from, the data ob- 
tained. 

The pleasantest plane mirror is one of 4 cm. diameter, and oi 
which the sight-hole is 4 mm. in diameter. 



FOCAL OR OBLIQUE ILLUMINATION. 

is employed for the examination of the cornea^ iris, and anterior 
part of the lens. With a high -|- l^ns (16 to 18 D) the light of 
the gas flame is concentrated on the part to be examined with 
an oblique, not a perpendicular, incidence of the concentrated rays. 
Small foreign bodies in the iris, cornea, or lens, or opacities in 
either of the latter can be thus detected. Extremely delicate opac- 
ities in the cornea are not seen best with the strongest illumina- 
tion which can in this way be produced, but rather by the half- 
light which is obtainable at the edge of the cone of light passing 
from the lens. In examining the center of the crystalline lens the 
incidence of the light must necessarily be more perpendicular. 

But opacities in the refracting media can be best observed by 
examination with strong convex lenses in the upright image. 
The farther forward the opacity lies the more hypermetropic (so 
to speak) it is, and the stronger the lens required. Very minute 
opacities of the cornea can be seen in this way with a ;-|- 18 D 
or -}- 20 D lens in the ophthalmoscope. 



88 DISEASES OF THE EYE, 



THE NORMAL FUNDUS OCULI AS SEEN WITH 
THE OPHTHALMOSCOPE. 

Reference has been made to the enlargement of the image of 
the fundus oculi seen with the ophthahnoscope. The cause of 
this enlargement is that the fundus is observed through a dioptric 
system at or close to the principal focus of which it is situated, 
and which consequently magnifies it to our view. The enlarge- 
ment of the inverted image is not so great as that of the upright 
image, and it is smaller the shorter the focal length of the convex 
lens employed. The inverted image of a hypermetropic eye is 
larger than that of an emmetropic eye, and the latter larger than 
that of a myopic eye. It is possible to determine mathematically 
the degree of enlargement of the image; but into this it is not 
necessary to enter. 

The Optic Papilla, or Optic Disc. — This is the first object to 
be sought for by the observer. It presents the appearance of a 
pale pink disc, somewhat oval in shape, its long axis being vertical. 
Occasionally the long axis lies horizontally, and sometimes the 
papilla is circular. The papilla is generally surrounded by a 
white ring, more or less complete, called the sclerotic ring, and 
often, outside this again, by a more or less complete black line, the 
chorioidal ring. The sclerotic ring is due to the chorioidal margin 
not coming quite up to the margin of the papilla, the foramen in 
the chorioid for the passage of the optic nerve fibers being some- 
what larger than that in the sclerotic, and, consequently, a narrow 
edging of the white sclerotic is exposed. The chorioidal ring is the 
result of a hyperdevelopment of pigment at the margin of the 
chorioidal foramen. The complexion of the optic disc results from 
the pink hue derived from its fine capillary vessels, combined with 
the whiteness of the lamina cribrosa and the bluish shade of the 
nerve fibers. It is frequently not equal all over, but is paler on 
the outer side, where the margin is more defined and where the 
nerve fibers are often fewer than on the inner side. The apparent 
color of the papilla depends also upon the complexion of the rest 
of the fundus. If the latter be highly pigmented, the papilla ap- 
pears pale in contrast ; while, if there be but little pigment in the 
chorioid, the papilla may appear very pink. The complexion of 
every normal papilla is not identical, and care must be taken not 
to make the diagnosis *' Hyperemia of the papilla " where merely 



THE NORMAL FUNDUS OCULI. 89 

a high physiological complexion is present. The upper and lower 
margins of the papilla are often, especially in young people, a little 
indistinct, and show a delicate striation by the direct method of ex- 
amination. This may be greatly exaggerated in hypermetropes, 
and has in them been sometimes erroneously taken for optic 
neuritis. 

A physiological excavation of the optic papilla is often met with. 
It is always on the temporal side of the papilla, and can be recog- 
nized from the parallax* which may "be produced, and from the 
paleness of this portion of the papilla. When the excavation is 
very deep, one may sometimes observe the lamina cribrosa in the 
form of gray spots (the nerve fibers) surrounded by white lines 
(the fibrous tissue of the lamina). 

A physiological excavation differs from a pathological excava- 
tion by the fact that it does not reach the margin of the papilla all 
round. It is caused by the crowding over of the nerve fibers to the 
inner side of the papilla. Yet sometimes a healthy optic papilla will 
be met with in which the excavation apparently reaches the margin 
all round. Doubtless in such cases the thickness of the trans- 
lucent nerve-fiber layer alone it is which is interposed between the 
sclerotic margin and the margin of the cup all round. 

The Normal Retina is so translucent that it cannot be seen, 
or at most a shimmering reflection or shot-silk appearance is ob- 
tained from it, particularly about the region of the yellow spot 
and along the vessels, but also towards the equator of the eye, 
and especially in dark eyes, and in young people. 

A peculiar, but physiological, appearance known as " opaque 
nerve fibers " is occasionally seen. It is produced by some of the 
nerve fibers forming the internal layer of the retina regaining the 
medullary sheath on the distal aspect of the lamina cribrosa, or 
near the margin of the papilla, which they had lost in the optic 
nerve just before entering the lamina cribrosa ; the rule being that 
the nerve fibers lose their medullary sheath at the latter place 
definitely, and enter the retina as axis cylinders only, and hence 
are quite translucent. Instead of that, in these cases their fibers 
reflect the light strongly, giving the effect of an intensely white 
spot, commencing at the disc, extending more or less into the 
surrounding retina, and terminating in a brushlike extremity. This 
appearance is constant in the rabbit's eye. 

The Macula Lutea is generally seen as a bright oval ring 

* For explanation of the parallax see chap. xii. 
8 



go 



DISEASES OF THE EYE. 



with its long axis horizontal, this ring being probably a reflex 
from the surface of the retina. It is remarkable that this halo is 
not visible with the direct method of examination — a fact due 
probably to the illumination being much weaker than with the 
indirect method. The area inside the ring is of a deeper red than 
the rest of the fundus, and at its very center there is an intensely 
red point, the fovea centralis. This ring is not seen in old people. 
The General Fundus Oculi surrounding the optic papilla and 
macula lutea varies a good deal in appearance according to the 




Fig. 44 — (Graefe and Sacmisch). 
a. n. s., Art. nas. sup. ; a. n. i., Art. nas. inf. ; a. i. s., a. t. i., A. temp. sup. 
and inf. ; v. n. s., v. n. i., Ven. nas. sup. and inf. ; v. t. s., v. t. i., Ven. temp, 
sup. and inf.; a. m. e., v. m. e., Art. and ven. median; a. m., v. m.. Art. and 
ven. macularis. 

amount of pigment contained in the chorioid and in the pigment- 
epithelium layer of the retina, i. If there be an abundant supply 
of pigment in each of these positions, the chorioidal vessels are 
greatly hidden from view, and the efifect is that of a very dark red 
fundus. 2. If there be but little pigment in the pigment-epithe- 
lium layer, the larger chorioidal vessels may be visible, and the 



THE NORMAL FUNDUS OCULI. 91 

fundus may appear to be divided up into dark islands surrounded 
by red lines. 3. If the individual be a blonde, there is little pig- 
ment either in the pigment-epithelium layer or in the chorioid, and 
the fundus is seen of a very bright red color, the chorioidal ves- 
sels down to their fine ramifications being discernible. In albinos 
even the chorioidal capillaries may be seen. 

The Retinal Vessels. — The arteries are recognized as thin 
bright red lines running a rather straight course, in the center of 
each of which is a light-streak. As to the cause of this light- 
streak there is considerable divergence of opinion. Some at- 
tribute it to reflection from the coats of the vessel, or from the 
surface of the blood column ; while others believe that the light is 
reflected from the fundus through the vessel, which then acts as a 
very strong cylindrical lens. This light-streak divides the vessel 
into two red lines. The veins are darker, wider, and more tor- 
tuous in their course than the arteries, and, their coats not being 
so tense, the light-streak is very much fainter. 

On reaching the level of the nerve-fiber layer of the retina the 
central artery and vein divide into a principal upper and lower 
branch. This first branching often takes place earlier in the vein 
than in the artery, and the former may even branch before ap- 
pearing on the papilla, as in Fig. 44. The second branching may 
take place in the nerve itself ; and when this occurs it will appear 
as though four arteries and four veins sprang from the optic 
papilla ; but more usually this branching occurs on the papilla, as in 
Fig. 44. The vessels produced by this second branching pass re- 
spectively towards the median and temporal side of the retina, and 
are termed by Magnus the Art. and Ven. nasalis and temporalis 
sup. and inf. (vide Fig. 44). The temporal branches run in a 
radial direction towards the anterior part of the retina. A small 
horizontal branch, the Art. and Ven. mediana of Magnus, from 
the first principal branches is found passing towards the nasal side 
of the retina. The temporal branches do not run in a horizontal 
direction, but make a detour round the macula lutea, sending fine 
branches towards the latter. Two or three minute vessels from 
principal branches run directly from the papilla towards the 
macula lutea, and around the macula lutea a circle of very fine 
capillary vessels is formed which cannot be distinguished with 
the ophthalmoscope ; but no vessels run to, or cross over, the fovea 
centralis itself. The retinal arteries do not anastomose, nor do the 
larger retinal veins. The small retinal veins have some slight 



92 DISEASES OF THE EYE. 

anastomoses near the ora serrata. Occasionally a vessel emerges 
near the margin of the disc, usually at the temporal side. It arises 
from the ciliary vessels, and is hence called a cilio-retinal vessel. 

No pulsation of the arteries is observable in the normal eye. 
In the larger veins near or on the optic papilla, or more usually 
just at their point of exit, a pulsation may sometimes be seen. 
This venous pulsation is due to the following sequence of events : 
Systole of the heart ; diastole of, and high tension in, the retinal 
arteries ; consequent increased pressure in the vitreous humor ; 
communication of this to the outside of the walls of the retinal 
veins, impeding the flow of blood through them, especially in 
their larger trunks, which offer little resistance, or at their exit 
from the eye, where they offer the least resistance ; and in this 
way the veins are emptied — the blood gradually coming on from 
the capillaries overcomes the resistance, and the veins are for a 
moment refilled. The phenomenon can be most readily observed if 
the normal tension of the globe be slightly increased by pres- 
sure of a finger. 



CHAPTER IV. 
DISEASES OF THE CONJUNCTIVA. 

The Conjunctiva consists of three portions: the palpebral, 
Hning the inside of the eyehds ; the bulbar, covering the sclerotic ; 
and a loose folded portion, uniting these two, which forms the 
sulcus or fornix, upper and lower. When the conjunctiva reaches 
the margin of the cornea it overlaps the latter slightly, and this 
overlapping portion is known as the liiiibus conjunctivae, or cor- 
nea. 

Hyperemia of the Conjunctiva. — In this condition the blood- 
vessels of the palpebral conjunctiva are especially engaged. 
Slight chemosis sometimes appears, small vesicles may form, and 
there may be some swelling of the papillae and development of 
lymph follicles. Yet there is not any abnormal discharge from 
the conjunctiva, and herein lies the chief point of difference be- 
tween this affection and simple conjunctivitis. 

Causes. — Foreign bodies. Foul air, or air loaded w^ith tobacco- 
smoke. Alcoholic excesses. Accommodative asthenopia. Sten- 
osis lacrimalis, and other forms of lacrimal obstruction. The use 
of unsuitable spectacles, or the use of the eyes for near work 
without spectacles when the condition of the accommodation {e. g., 
hypermetropia, presbyopia) requires them. 

Symptoms. — The eyes are irritable. There is lacrimation and 
photophobia, with hot, burning sensation, and sensations as of a 
foreign body in the eye, and the eyelids feel heavy. All these 
symptoms are aggravated in artificial light. 

Treatment. — In addition to the removal of the cause, the in- 
stillation of a drop of tincture of opium and distilled water in 
equal parts morning and evening will be found beneficial. The 
eyes should be protected from the glare of light by dark glasses, 
and out-of-door exercise is to be recommended. 

Conjunctivitis in general. — In addition to hyperemia there 
is here abnormal secretion. There are several forms of con- 
junctivitis, the discharge from each being more or less infectious. 
The secretion from any given form will not, however, always re- 

93 



94 DISEASES OF THE EYE. 

produce that form, but may give rise to another of greater or less 
severity. Infection takes place by the direct application of the 
secretion, or also — it is very generally thought — through the air, 
in which float particles of the infecting substance. This latter 
mode is especially liable to exist in an ill-ventilated room, where 
a number of people affected with conjunctival diseases are lodged 
with others who possess healthy eyes — e. g., in crowded charity- 
schools. It must be stated, however, that some authorities dis- 
pute the possibility of air-borne infection, upon the ground that 
most of the organisms which cause the various forms of infectious 
conjunctivitis are non-sporing, and are readily killed by drying. 
The palpebral conjunctiva is often afifected when the bulbar por- 
tion remains normal, and the conjunctiva of the lower lid is more 
frequently attacked than that of the upper lid. 

Catarrhal, or Simple Acute, or Muco-purulent Conjuncti- 
vitis. — In mild cases the affection is confined to the palpebral 
conjunctiva, often even to the conjunctiva of the lower lid; but in 
the severer cases it extends to the bulbar conjunctiva. Lymph 
follicles and enlarged papillae are frequently present, but not neces- 
sarily so. There is a sticky, thin, mucous, or muco-purulent se- 
cretion, which causes the eyelids to be fastened together on awak- 
ing in the morning, and sometimes produces ulceration of the in- 
termarginal portion of the eyelids (intermarginal blepharitis). In 
some of the very mildest cases this '' stickiness " or '' gumming " 
on awaking in the morning is a valuable diagnostic sign, for it is 
in such cases difficult or impossible to recognize the very slight 
variation from the healthy appearance of the conjunctiva. 

In the severer cases the papillse are markedly swollen, and may 
even conceal the Meibomian glands from view. Also one often 
sees small ecchymoses in the bulbar conjunctiva, especially in cer- 
tain epidemics ; but these have no serious import. 

Minute gray infiltrations sometimes form at the margin of the 
cornea. When there are many of them they may become con- 
fluent and form a small gray crescent, which ulcerates, and thus a 
crescentic marginal ulcer is formed, and very occasionally such an 
ulcer is followed by iritis. 

The catarrh may become chronic, and then the papillae are more 
developed, while the blepharitis is liable to extend over to the 
cutis, causing eversion of the lower punctum lacrimale with 
resulting lacrimation, and this, in its turn, aggravates the con- 
junctival affection. 



THE CONJUNCTIVA. 95 

The Koch-Weeks bacilkis is the specific bacillus of acute con- 
junctivitis. It can be cultivated on human serum only, and that 
with difficulty.^ A very mild form of acute conjunctivitis is pro- 
duced by the diplobacillus of Morax,^ and the pneumococcus is 
also capable of setting up a mild conjunctivitis. 

The Symptoms are those of a severe case of hyperemia (sensa- 
tions of sand in the eye ; hot, burning sensations ; weight of the 
eyelid), with the addition of the annoyance consequent on the 
secretion, which, by coming across the cornea, may cause mo- 
mentary clouding of sight. Photophobia is not generally severe 
unless there be some corneal complication. 

Causes. — Draughts of cold air. Contagion. Foul atmosphere. 
As an epidemic. Foreign bodies. As a sequel of or attendant on, 
scarlatina, measles, and smallpox. 

Diagnosis. — The presence of the gummy secretion distinguishes 
this affection from mere hyperemia of the conjunctiva. A com- 
mon mistake amongst those not familiar with eye diseases is 
to regard a case of iritis as one of simple acute conjunctivitis, the 
redness of the white of the eye in the former affection being taken 
for conjunctival hyperemia, etc., and, moreover, a slight secondary 
conjunctivitis does undoubtedly attend many cases of iritis. 

The circumcorneal subconjunctival vessels, which are the epi- 
scleral branches of the anterior ciliary vessels, are those which 
become engorged in iritis, and their engorgement gives rise to a 
pink or pale violet zone around the cornea, of which the separate 
vessels cannot be distinctly seen. The conjunctival vessels may 
be distinguished from the subconjunctival or ciliary vessels by 
the possibility of moving the former along with the membrane in 
which they are, by manipulations which can be made with the 
lower lid of the patient, while these manipulations do not affect 
the ciliary vessels. The separate conjunctival vessels, too, can 
be easily distinguished, and they are of a bright red color. The 
appearance of the iris itself, however, is that upon which the 
diagnosis finally depends. (See Iris, chap, x.) 

The Prognosis is good if there be no reason to suspect that 
the mild form is but the commencement of a more severe in- 
flammation. The infiltrations, and even the ulcers, which some- 
times form at the margin of the cornea are not often of serious im- 
port, and usually heal according as the treatment restores the con- 
junctiva to health. 

Treatment. — Cold or iced compresses, with the use of a i in 



96 DISEASES OF THE EYE. 

5CXX) solution of sublimate as a lotion, should be used frequently 
at the first onset, and in mild cases will alone bring about a cure. 
But the habit, which some patients so readily acquire, of bathing 
the eyes frequently with cold water should not be permitted, for 
it is deleterious to the conjunctival affection. When in a day or 
two the irritation and swelling have somewhat subsided — or from 
the very commencement, if there be no such irritation — a solution 
of nitrate of silver, of from 5 to lo grains to 5J, should be applied 
by the surgeon to the palpebral conjunctiva with a camel's-hair 
pencil, the lid being well everted, and this then should be thor- 
oughly neutralized with a saturated solution of common salt, the 
whole being finally washed off with plain water. The neutraliza- 
tion with salt water is very important to check prolonged action of 
the nitrate of silver, as also to obviate conjunctival staining when 
the treatment is a lengthened one. The application is to be re- 
peated after twenty-four hours, by which time the slight loss of 
epithelium, the result of the superficial slough, will have been 
repaired. Immediately after such an application cold sponging 
or iced compresses are useful, and grateful to the patient. The 
greatest care is required in the use of nitrate of silver in con- 
junctival affections for any prolonged period, lest it cause that 
brownish staining of the membrane called Argyrosis {apyvpo?, 
silver) ; thorough neutralization and washing, as above recom- 
mended, being the best safeguards. I am opposed to the use even 
of weak solutions of nitrate of silver as eye-drops to be used at 
home by the patient, for staining is very apt to be caused in this 
way. 

The application of a 20 per cent, solution of protargol to the 
conjunctiva with a camel's-hair brush is effective in many cases. 
It also is liable to cause argyrosis. Ichthargan in a 2 per cent, 
solution can be similarly used. 

Should the surgeon be unable to see the patient daily, the fol- 
lowing simple eye-drops are capable of effecting a rapid cure in 
most cases : IjJ Acid Boracici, gr. v ; Zinci Sulph. gr. ii ; Tinct. 
Opii, §j ; Aq. destill. ad 5J ; one drop in the eye morning and 
evening, or only once a day in mild cases. Solutions of alum 
(gr. iv to §j of water) and of tannic acid (gr. v to viij to §j of 
water) are often prescribed, but are not so effectual as the fore- 
going. 

A weak boracic acid ointment, to be applied along the margins 
of the lids at bedtime, is to be ordered. It prevents the gummi- 



THE CONJUNCTIVA. 97 

ness in the morning, which is not only unpleasant to the patient, 
but is also injurious, by fastening the eyelids together, and thus 
preventing free drainage of the secretion during the night. 

Acute Blennorrhea of the Conjunctiva, or Purulent Oph- 
thalmia. — We most commonly find this very dangerous affection 
either as gonorrheal ophthalmia or as blennorrhea neonatorum. 

Etiology. — In gonorrheal ophthalmia the etiological moment is 
the introduction of some of the specific discharge from the urethra 
or vagina into the conjunctival sac; while in the latter the infec- 
tion is believed to take place, either during or just after the pas- 
sage of the head through the vagina, by an abnormal secretion 
from the latter finding its way into the infant's eyes. A few in- 
stances have been observed of infants born with the disease. In- 
oculation may also occur a few days after birth by pus con- 
veyed by the fingers of the mother or nurse, or by towels, etc., used 
for washing the child's face. It is never due to exposure to strong 
light or to cold, as is popularly supposed. 

The more severe cases of blennorrhea neonatorum are caused by 
a vaginal discharge, which is always gonorrheal. Neisser, who 
first observed the presence of a peculiar micrococcus in the gonor- 
rheal discharge, also found the gonococcus in the pus from the 
conjunctiva in cases of gonorrheal ophthalmia, and the same mi- 
crococcus has been found in the conjunctival discharge in cases of 
blennorrhea neonatorum. But the slight cases of the latter affec- 
tion, which amount to little more than a catarrh of the conjunctiva, 
may be caused by a vaginal discharge, which is not of the specific 
gonorrheal nature. 

If the infection take place during or immediately after birth, 
the disease appears from the second to the fifth day, according 
to the virulence of the secretion. If the inflammation come on 
later than the fifth day, it may be concluded that the infection 
was produced by the vaginal discharge being introduced into the 
eye by the fingers of the mother or nurse, etc. Acute conjunctival 
blennorrhea also comes about without any assignable cause ; but 
in all such cases it may be regarded as certain that the intro- 
duction of some infective pus into the eye has taken place, al- 
though without the knowledge of the patient. 

Symptoms and Progress. — In mild cases the bulbar conjunctiva 
may be but little, or not at all, affected, the palpebral conjunctiva 
alone becoming velvety and discharging a small amount of pus, 
while there may be no swelling or edema of the eyelids. Such mild 



98 DISEASES OF THE EYE. 

cases are not uncommon in ophthalmia neonatorum, and indeed 
some of these mild cases cannot be classed as purulent ophthalmia, 
owing to absence of the gonococcus and presence of the Koch- 
Weeks and other bacilli. In severe cases of blennorrhea of the 
conjunctiva there is, soon after the onset, serous infiltration of the 
palpebral mucous membrane — which consequently becomes tense 
and shiny — serous chemosis (.ifazVu?, to gape open/^) of the bulbar 
conjunctiva, serous discharge, dusky redness and swelHng of the 
eyelids — which make it difficult to evert them — pain in the eyelids, 
often of a shooting kind, burning sensations in the eye, and pho- 
tophobia. This first stage lasts from forty-eight hours to four or 
five days. 

Then begins the second stage, in which, owing to swelling of 
the papillae, the palpebral conjunctiva becomes less shiny and 
more velvety ; while the discharge alters from serous to the char- 
acteristic purulent form, the chemosis, however, remaining unal- 
tered, or becoming more firm and fleshy. The swelling of the 
lids continues, the upper lid often becoming pendulous and hang- 
ing down over the under lid ; while, at the same time, it becomes 
less tense and more easily everted. Gradually the chemosis and 
swelling of the conjunctiva and eyelids subside, and the discharge 
lessens, the mucous membrane finally being left in a normal state, 
unless in a small percentage of cases in which chronic blennorrhea 
remains. A moderately severe attack of conjunctival blennor- 
rhea lasts from four to six weeks. 

Complications with corneal affections form the great source of 
danger from this affection. They are found chiefly in four differ- 
ent forms : ( i ) Small epithelial losses of substance on any part 
of the cornea. If these occur at the height of the inflammation, 
they are apt to go on to form deep perforating purulent ulcers. 
(2) The whole cornea becomes opaque (diffusely infiltrated), and 
towards its center some grayish spots form, which are inter- 
stitial abscesses or purulent infiltrations. (3) The infiltration may 
form at the margin of the cornea, and extend a considerable dis- 
tance around its circumference, giving rise to a marginal ring 
ulcer, and, later on, to sloughing of the whole cornea. (4) A 
clean-cut ulcer may fonn at the margin of the cornea without any 
purulent infiltration of the corneal tissue, and may also extend 
a long way round the cornea. Such ulcers are particularly apt to 

* From the appearance produced when the conjunctiva in this condition 
is much elevated round the margin of the cornea. 



THE CONJUNCTIVA. 99 

occur where there is much chemosis which overlaps the margin 
of the cornea; and, being hidden in this way, these ulcers are 
easily overlooked. The chemosis should be pushed aside with a 
probe, and these peculiar ulcers looked for. They are very liable 
to perforate. 

All the foregoing forms of corneal complications occur both 
in ophthalmia neonatorum and in gonorrheal ophthalmia. They 
may appear at any period of the affection, but the earlier they 
occur the more likely are they to result seriously. 

The danger of these ulcers consists in the perforation of the 
cornea they are apt to produce, of which more later on. 

The severer the case, especially the more the bulbar con- 
junctiva is involved in the process, the more likely is it that 
corneal complications will arise. For the corneal process is to 
be regarded as the result of infection by the conjunctival secretion; 
and this infection is all the more apt to occur where the nutrition 
of the cornea is impeded by a dense chemotic swelling of the bul- 
bar conjunctiva. Severe chemosis is less common in the blennor- 
rhea of the new-born than in gonorrheal ophthalmia, and this 
may be the reason for the fact that the latter is much the more 
dangerous affection of the two. 

The Prophylaxis of purulent ophthalmia is a most important 
matter. It should form part of the routine of lying-in practice. 
Careful disinfection of the vagina before and auring birth, and 
the most minute care in cleansing the face and eyes of the infant 
immediately after birth with a non-irritating disinfectant (e. g., 
a solution of corrosive sublimate i in 5000), are to be recom- 
mended. The method of the late Dr. Crede has found very gen- 
eral acceptance, and is an admirable one. It is as follows : When, 
after division of the umbilical cord, the child is in the bath, the 
eyes are carefully washed with water from a separate vessel, the 
lids being scrupulously freed, by means of absorbent wool, of all 
blood, slime, or smeary substance ; and then, before the child is 
dressed, a few drops of a 2 per cent, solution of nitrate of silver 
are instilled into the eye. Many obstetricians employ this method 
now as a matter of routine in their lying-in hospitals for all the 
infants, whether or not it be suspected that there is danger of in- 
fection. By its aid Crede reduced the percentage of his cases of 
ophthalmia neonatorum from 8 or 9 per cent, to 0.5 per cent. 

In all cases of gonorrhea it is the duty of the surgeon to explain 
to his patients what is the danger of their carrying any of the ure- 



'G. 



lOO DISEASES OF THE EYE. 

thral discharge to their eyes ; and to charge them to exercise 
punctiUous cleanhness as regards their hands and finger-nails, and 
care in the use of towels, handkerchiefs, etc. 

In respect of Local Treatment when the disease has once broken 
out : In the very commencement of the affection the only local ap- 
plications admissible are antiseptic lotions (Permanganate of Pot- 
ash Solution, I in 10,000; Sublimate, i in 5000) and iced com- 
presses, or Leiter's tubes. With the former the conjunctival sac 
should be freely washed or irrigated — not syringed — out. In syr- 
inging out the conjunctival sac a morsel of the corneal epithelium 
may be removed, and through this the cornea become infected, 
and, therefore, this method is objectionable. The iced compresses, 
or Leiter's tubes, should be kept to the eye for an hour at a time, 
with a pause of an hour, and so on, or even continuously. In 
this and in the next stage the chemosis should be freely, and 
daily, incised with scissors. If the swelling of the lids be great, 
the external canthus should be divided with a scalpel from with- 
out, leaving the conjunctiva uninjured, in order to reduce the 
tension of the eyelids on the globe, and, by bleeding from the 
small vessels, to deplete the conjunctiva. Depletion alone can be 
obtained by leeching at the external canthus, and in many cases is 
of great benefit at the very commencement. If in adults the 
chemosis, palpebral swelling, and rapidity of the onset indicate 
that the inflammation is severe, it is well, in my opinion, to place 
the patient quickly under the influence of mercury by means of in- 
unctions or small doses of calomel, as by so doing the chemosis 
is often rapidly brought down, and one source of danger to the 
cornea removed. 

In the second stage (/. e., when the conjunctiva has become vel- 
vety, and the discharge purulent) caustic applications are the most 
trustworthy, and in this respect iodoform and other lauded means 
cannot compete with them. The application employed may be a 
solution of nitrate of silver of 15 to 20 grains in oj of water, which 
should be applied by the surgeon to the conjunctiva of the everted 
lids, and then neutralized with a solution of common salt, as de- 
scribed when discussing the treatment of simple catarrhal con- 
junctivitis; or the solid mitigated nitrate of silver (one part nitrate 
of silver, two parts nitrate of potash) may be used, the first ap- 
plication being lightly made in order to test its effect, while careful 
neutralization with salt water and subsequent washing with fresh 
water are most important. No remedy is of greater value in puru- 



THE CONJUNCTIVA. loi 

lent ophthalmia than mitigated lapis, when the proper indications 
for its use are present, and when it is applied with care and in- 
telligence. 

The immediate effect of a caustic application to the conjunctiva 
is the production of a slight slough, under which a serous infiltra- 
tion takes place. This latter increases and finally throws off the 
slough, and then the epithelium begins to be re-formed. From the 
time the slough separates until the epithelium has been regenerated 
a diminution in the secretion may be noted ; but the discharge 
again increases as soon as the regenerative period is ended, and this 
now is the moment for a new application of the caustic. From 
one caustic application of ordinary severity until the end of the re- 
generative period about twenty-four hours usually elapse. Imme- 
diately after a caustic application iced compresses should be used 
for thirty minutes or longer. Between the caustic applications 
the pus should be frequently washed away from the eyelids and 
from between the eyelids with a 4 per cent, solution of boric acid, 
or with a I in 5000 solution of corrosive sublimate, and boric acid 
ointment should be smeared along the palpebral margins, to pre- 
vent them from adhering, and thus retaining the pus. 

No corneal complication contra-indicates the active treatment 
of the conjunctiva by the method just described. Iodoform, finely 
pulverized, has been much praised as a local application in the 
second stage of acute blennorrhea of the conjunctiva. It is to be 
dusted freely on the conjunctiva once or twice a day. For my 
part I should trust to it in mild cases only. 

Permanganate of potash in solution (i in 10,000) is strongly 
recommended by Kalt and by Leber^ as a substitute for nitrate of 
silver even in severe cases. They state that it can be used from 
the beginning, and with greater benefit. It is used as a wash four 
times a day. 

When but one eye is affected it is important to protect its fellow 
from infection by means of a hermetic bandage. This may be 
made by applying to the eye a piece of lint covered with boracic 
acid ointment, and over this a pad of borated cotton-wool. Across 
this, from forehead to cheek and from nose to temporal region, are 
laid strips of lint soaked in collodion in layers over each other ; 
or a piece of tissue putta-percha may take the place of the lint and 
collodion, its margins being fastened to the skin by collodion. 
The shields invented by Maurel and by Buller are serviceable for 
this purpose. 



102 DISEASES OF THE EYE. 

Treatment of Corneal Complications. — Many surgeons, I under- 
stand, use solution of the sulphate of eserin (gr. ij ad aq. 5j), 
dropped into the eye as soon as any corneal complication arises, and 
as long as it continues, on the ground that this drug is believed to 
have the effect of reducing the intra-ocular tension (a circum- 
stance to be desired in these instances), and also to act as an anti- 
septic. Its power to reduce the normal intra-ocular tension is not 
great, and its antiseptic action, if it exist, must be very insignifi- 
cant, while, in my opinion, it has a decided tendency to promote 
iritis in these cases, where the iris is so liable to become inflamed 
secondarily to the corneal process. I therefore do not recommend 
its use in these cases. I employ atropin here with the object of 
diminishing the tendency to iritis. Only if a marginal ulcer should 
perforate, with prolapse or danger of prolapse, into the open.ing, 
is eserin indicated, and then simply for the purpose of drawing 
the iris out of, or away from, the perforation by the contraction of 
its sphincter. 

On the first appearance of an ulcer or infiltration of the cornea, 
besides the use of atropin, nothing can be done further than the 
steady continuance of the conjunctival treatment, no remission or 
relaxation of which is indicated or, indeed, admissible. Greater 
care is now required in everting the lids, lest pressure on the globe 
might cause rupture of the ulcer; and it should be remembered 
that when a case of acute blennorrhea first presents itself, the 
surgeon, not knowing the condition of the cornea, must use the 
utmost caution in making his examination, and yet must' never 
fail to get a view of the cornea for the purposes both of prognosis 
and of treatment. At each visit the cornea must be examined, and 
it may be found that, as the conjunctival process subsides, any ex- 
isting corneal affection also progresses towards cure, infiltrations 
becoming absorbed and ulcers filled up. But even though the 
conjunctiva be improving, and still more so if it be not, the 
corneal process may progress, the infiltration becoming an ulcer, 
and the ulcer becoming gradually deeper, until, finally, it per- 
forates. 

Should a corneal ulcer become deep, and seem to threaten to 
perforate, paracentesis of the floor of the ulcer must be resorted 
to without delay. By thus forestalling nature a short linear open- 
ing is substituted for the circular loss of substance, which would 
have resulted in the ordinary course of events. Through this 
small linear opening no prolapse of the iris, or else a relatively 



THE C0^7UNCTIVA. 103 

small one, takes place ; and, consequently, the ultimate state of the 
eye is usually a better one than it otherwise would have been. The 
reduction of the intra-ocular tension after the paracentesis pro- 
motes healing of the ulcer. It is often desirable to evacuate the 
aqueous humor, by opening the little incision in the floor of the 
ulcer with a blunt probe, on each of the two days after the 
operation. 

If an ulcer perforate spontaneously, the aqueous humor is evacu- 
ated, and, unless the ulcer be opposite the pupil and at the same 
time small in size, the iris must come to be applied to the loss of 
substance. Should the latter be very small, the iris will simply 
be stretched over it and pass but little into its lumen, and when 
healing takes place will be caught in the cicatrix, which is but 
slightly, or not at all, raised over the surface of the cornea, and the 
resulting condition is called Anterior Synechia. 

If the perforation be larger, a true prolapse of a portion of 
the iris into the lumen of the ulcer takes place. This prolapse 
may either act as a plug, filling up the loss of substance and 
keeping back the contents of the globe, but not protruding over 
the level of the cornea, or it may bulge out over the corneal sur- 
face as a black globular swelling, and may then play the part of a 
distensor of the opening, causing fresh infiltration of its margins. 
In either case cicatrization will eventually occur ; and if the scar 
be fairly flat, it is called an Adherent Leukoma, but if it be bulged 
out, the term Partial Staphyloma of the Cornea is used. 

If the perforation be very large, involving the greater part of 
the cornea with prolapse of the whole iris and closure of the pupil 
by exudation, the result is a Total Staphyloma of the Cornea. The 
lens may lie in this staphyloma, or it may retain its normal posi- 
tion, but become shrunken. 

The question of the treatment of a recent prolapse of the 
iris in cases of blennorrheic conjunctivitis is an important one. It 
has been, and is still largely, the practice to abscise small iris-pro- 
trusions down to a level with the cornea, or if large to cut a small 
bit off their summits, with the object of obtaining flat cicatrices. 
Horner ^ pointed out that in cases of blennorrhea this proceeding 
opens a way for purulent infection of the deep parts of the eye, 
and that serious consequences are not rare. He confined inter- 
ference with the iris in these eyes to incision of the prolapse, when 
it seems to be acting as a distensor of the opening, causing fresh 
infiltration of the cornea. Under other circumstances he restricted 



104 DISEASES OF THE EYE. 

his treatment of the prolapse to the instillation of eserin, which 
has a marked effect in diminishing the size of the protrusion. 

It may occur that on the surgeon's visit to a case of blennor- 
rhea of the conjunctiva he will find the margins of the eyelids 
gummed together by sero-purulent secretion, while the eyelids are 
bulged out by the pent-up fluid behind them. The attempt to 
open the eye should then be very cautiously made, lest some of 
the retained pus spurt into the surgeon's eye. The surgeon should 
also be most careful to thoroughly wash and disinfect his hands and 
nails at the conclusion of his visit. 

In cases of blennorrhea neonatorum, when the ulcer has been 
small, on perforation taking place, the lens, or rather its anterior 
capsule, comes to be applied to the posterior aspect of the cornea. 
The pupillary area is soon filled witli fibrinous secretion. The 
opening in the cornea ultimately becoming closed, the iris and lens 
are pushed back into their places by the aqueous humor which 
has again collected. Adherent to the anterior capsule on the spot 
which lay against the cornea is a morsel of fibrin, which gradually 
becomes absorbed by the aqueous humor. In the meantime 
changes have been produced by this exudation on the correspond- 
ing intracapsular cells, which result in a small, permanent, cen- 
tral opacity at that place, where there is also a slight elevation 
of pyramidal shape over the level of the capsular surface. This 
condition is called central capsular cataract, or pyramidal cataract, 
and rarely results from corneal perforation in adults. 

In cases of blennorrhea neonatorum an inflammatory swelling 
of the joints, so-called gonorrheal arthritis, is very occasionally 
seen. Deutschmann ^ found the gonococcus in the fluid removed 
from the joints in two such cases, while other observers found in 
their cases only the usual pyogenic cocci. Even more rarely do 
peri- and endocarditis, pleuritis, and meningitis occur. 

Follicular Conjunctivitis. — This is catarrhal conjunctivitis, to 
which is added the presence in the conjunctiva of small round 
pinkish bodies the size of a pin's head, which disappear completely 
as the process passes off, leaving the mucous membrane as healthy 
as they found it. These little bodies are situated chiefly in the 
lower fornix of the conjunctiva, and may be discovered by ever- 
sion of the lower lid, when they will be seen arranged in rows 
parallel to the margin of the lid. Whether they are easily dis- 
covered or not depends on their size and number and on the 
amount of coexisting hyperemia or chemosis of the conjunc- 



THE CONJUNCTIVA. 105 

tiva. The structure of these bodies shows them to be lymph 
foHicles. 

Folhcular conjunctivitis is a very tedious affection, lasting often 
for months. According to Saemisch it is more apt to give rise to 
marginal ulceration of the cornea than the simple catarrhal form ; 
but I have not observed this to be so. I agree with those who 
hold that the disease has no clinical relation to trachoma, although 
some authors regard it as an early stage of the latter. 

The Symptoms are much the same as those of catarrhal con- 
junctivitis. Frequently there is little or no injection of the bulbar 
conjunctiva, and the chief symptom is asthenopia — an inability to 
continue near work for any length of time — and much distress in 
artificial light. Boys and girls from five to fifteen years of age 
are those most liable to this affection. 

Causes. — These are much the same as in simple catarrhal con- 
junctivitis. The long-continued use either of atropin or of eserin 
is liable to bring on the disease. 

Treatment. — The most useful remedy in this troublesome affec- 
tion is an ointment of sulphate of copper of from gr. ss to gr. ij 
in 5j of vaselin. The weaker ointments should be used at first, and 
later on the stronger ones if it be found that the eye can bear them. 
The size of half a pea of the ointment is inserted into the con- 
junctival sac with a camel's-hair pencil once a day. Eye-drops of 
equal parts of tincture of opium and distilled water are of use in 
some cases. Abundance of fresh air, with change from a damp 
climate or neighborhood to a dry one, is of importance. If the use 
of a solution of atropin have induced the disease, it should be dis- 
continued ; and if a mydriatic be still required, a solution of 
extract of belladonna (gr. viij ad §j) may be employed in its 
stead. 

Spring Catarrh. — The tarsal conjunctiva is invaded by hard 
flattened bodies of a pinkish color arranged close together, and 
known as the tesselated or pavement granulations. They are 
slightly pedunculated. The conjunctiva assumes a milky-like 
opacity. The bulbar conjunctiva becomes injected, slightly 
edematous, and at the limbus somewhat elevated with grayish 
swellings. All these appearances may be present in the same 
case, or any one (the bulbar appearances, or the pavement granu- 
lations, or the milky-like opacity) or two of them may be absent. 
The margin of the cornea itself is apt to be invaded with minute 
infiltrations. Very occasionally the cornea becomes seriously 
9 



io6 DISEASES OF THE EYE. 

complicated by the growth on the hmbus extending over a great 
portion, or even the entire cornea. There is some mucous or 
muco-purulent secretion, and the patient complains of the eyelids 
being stuck together in the morning, of difficulty of using the eyes 
for near work, of itching and burning sensations, and all these 
symptoms are increased by exposure to heat. The eyelids droop 
slightly, giving the patient a sleepy look. The swelling at the 
limbus is of a fibromatous structure. 

The affection makes its appearance with the advent of warm 
weather in the late spring or early summer, and generally disap- 
pears, or is much modified in the cool seasons, to return again 
with the next warm season, and this is liable to go on for a long 
series of years. 

The Treatment of the majority of these cases yields very un- 
satisfactory results. Protection glasses should be worn. So far 
as possible all exposure to great heat of sun or artificial heat should 
be avoided. Weak astringent collyria, or ointments, may be used ; 
or iodoform ointment ( i in 1 5 ) , a little put into the eye once a day, 
or massage twice daily in conjunction with yellow oxid ointment. 
De Schweinitz recommends boroglycerid locally, and arsenic in- 
ternally. Antipyrin and quinin internally have proved of use in 
some cases. For the tarsal granulations Theobald has found 
marked benefit from use of the roller forceps. 

Hay Fever. — This is not uncommon among the better classes 
in these countries, although it is rarely seen in our hospital out- 
patient departments. The symptoms, in those liable to it, appear 
in the early summer each year, and disappear again in the course 
of six weeks or two months. They consist in catarrh of the nos- 
trils, accompanied by great itching of them and frequent sneezing; 
while the conjunctiva, especially in the lower fornix, becomes 
somewhat hyperemic, and there is lacrimation. There is excessive 
itching of the eyes, which renders the patient most wretched, and 
forces him to rub his eyes violently. There is photophobia. The 
respiratory tract may become involved, with some bronchitis and 
asthma, and general malaise and elevation of temperature are 
present. Sometimes the eyes alone are affected. There is no 
tendency to corneal complications. 

Treatment is of no avail in preventing the annual recurrence of 
the affection, nor is it of much use in alleviating the attack. No 
strong local application should be employed. Weak collyria, or 
ointments, of sulphate of zinc, or copper, boric acid, or sublimate, 



THE CONJUNCTIVA. 107 

etc., may be tried. Cocain or holocain eye drops (2 per cent.) 
afford the best relief. Dark glasses should be worn. 

Trachoma {rpaxv^^, rough), Granular Conjunctivitis, or 
Granular Ophthalmia (also called Egyptian Ophthalmia and 
Military Ophthalmia). — In this disease, in addition to the usual 
appearances of simple conjunctivitis, there are developed grayish 
or pinkish gray bodies about the size of the head of a pin, situated 
in and close to the fornix conjunctivae, chiefly of the upper lid, but 
also disseminated over other parts of the membrane, except that 
they do not form on the bulbar conjunctiva. These bodies are the 
trachoma bodies or granulations, or so-called " sago " grains, and 
in the acute form of the disease they somewhat resemble the fol- 
licles of follicular conjunctivitis, but are paler, not so apt to occur 
in rows, and are more isolated. Microscopically, the trachoma 
bodies have no capsule, but seem to grow from, or in, the stroma 
of the conjunctiva. The trachoma bodies consist at first of lymph 
corpuscles alone ; but at a later period this is true of them only 
towards their surface, while at their bases they are formed chiefly 
of connective tissue. They are to be regarded as new growths in 
the conjunctiva. 

In addition to the true trachoma bodies, the luxuriant papillary 
growth, which so often springs up in the chronic cases, is crammed 
with lymph corpuscles, and these papillae are termed papillary 
trachomata, in contradistinction to the true granular trachomata. 

No specific micro-organism has as yet been discovered as the 
cause of trachoma. Leber ^ describes the presence of certain 
large cells containing peculiarly formed bodies in trachoma, and 
very probably these have to do with the pathogenesis of the 
affection. 

The disease comes under our notice in two forms — the acute 
and the chronic. The latter may result from the former, but it is 
much more common to find it as the primary condition, without 
any appreciable acute stage having gone before. 

Causes. — Both forms are contagious, and probably the infec- 
tion occurs only by transference of the secretion from one eye to 
the other by means of fingers, towels, handkerchiefs, etc. Hence 
the more slovenly in their personal habits, and the more crowded 
in their dwellings, families, schools, or barracks, nations may be, 
the more likely is this disease to spread from one individual to an- 
other when it once gains a foothold. x\ great deal, however, re- 
mains to be learned as to the manner in which contagion takes 



io8 DISEASES OF THE EYE. 

place. For instance, inoculation with discharge from an acute case 
may give rise only to catarrhal or purulent conjunctivitis, which 
may recover completely. Again, the infectiousness of chronic 
cases cannot be very great, for nurses and doctors rarely, if ever, 
become infected by their patients. Neither do we see trachoma 
patients infecting other patients in the hospitals in this country, 
where the disease is so prevalent. Were the infectiousness of the 
disease very great, even the precautions taken in a well-ordered 
hospital against contagion would hardly be sufficient to prevent 
such an occurrence occasionally. 

It has been stated that the acute form is often epidemic in places 
where the hygienic conditions are bad ; but in this country I have 
never seen it as an epidemic, and sporadically not often, although 
the chronic form is extremely common in Ireland. 

Amongst the better classes, both here and elsewhere, the disease 
is very uncommon. High, dry, mountainous countries are almost 
free from it, so that, probably, the atmospheric conditions play 
some part in the etiology. 

Some hold that the affection is dependent on constitutional dis- 
ease, such as scrofula, tuberculosis, syphilis, etc. ; but I cannot 
indorse this view. No doubt many of these patients are anemic 
and out of health, but this is due to the moping habits they con- 
tract, and the little open-air exercise they take in consequence of 
their semi-blindness. 

Acute Trachoma or Acute Granular Ophthalmia. — As al- 
ready stated, this is an affection rarely seen in this country. An 
attack commences with swelling of the upper lid, great injection 
of the whole of the bulbar and palpebral conjunctiva, and swelling 
of the papillae, with development of the characteristic trachoma 
bodies. There may be but little discharge ; but there is generally 
much lacrimation, with photophobia, and great pain in the brow 
and eye. Superficial marginal ulcers of the cornea may form. 

The inflammation and papillary swelling increase for a week or 
so to such a degree that the granulations are hidden from view ; 
and then, taking on a blennorrheic form, the process gradually sub- 
sides, until, in the course of two or three weeks longer, the blennor- 
rhea disappears, having brought about absorption of the trachoma 
bodies, and ultimately the mucous membrane is left in a healthy 
state. 

If, however, in the blennorrheic stage, the inflammation be ex- 
cessive, the eye may run all the dangers of an attack of acute puru- 



THE CONJUNCTIVA. 109 

lent conjunctivitis; or if, on the other hand, the inflammation be 
very sHght, it may not be sufficient to effect absorption of the 
granulations, and the process may run into the chronic forrn. 

Egyptian ophthalmia, which is an acute form of trachoma, seems 
to be a combination of trachomatous disease with purulent oph- 
thalmia, as the gonococcus can be found in the discharge."^ 

Treatment. — It is desirable to abstain from active measures in 
the commencement uf the affection, owing to the tendency to 
natural cure which is often present, and especially astringents and 
caustics should be avoided. At the utmost an antiseptic lotion of 
boric or salicylic acid, and cold applications for relief of the pain 
and heat are admissible. Dark protection-glasses are agreeable, 
and, wearing them, the patient should be encouraged to take open- 
air exercise. But if it be evident that the inflammatory reaction 
is not active enough, poultices or warm fomentations should be 
employed to promote it. Once the blennorrheic stage has been 
reached, great care is required to control it, and if it threaten to 
exceed safe bounds it must be restrained by means of suitable ap- 
plications, such as acetate of lead, nitrate of silver, or sulphate of 
copper in solutions of medium strength ; or it may be necessary to 
use them in strong solutions, or to employ the solid mitigated 
nitrate of silver. 

Chronic Trachoma or Chronic Granular Ophthalmia. — The 
first onset of this disease is often without inflammation, and is 
then unattended by any distressing symptoms, except that the eye 
may be more easily irritated by exposure to cold winds, for- 
eign bodies, etc., or more easily wearied by reading and other near 
work. At this period the conjunctiva will be found free from in- 
jection or swelling; but grayish-white semi-transparent trachoma 
bodies, of the size of a rape-seed and less, will be seen disseminated 
over the conjunctival surface and protruding from it. Gradually 
these trachoma bodies or granulations give rise to a more or less 
active vascular reaction, attended with swelling of the papillae and 
purulent discharge — in short, slight blennorrhea. The patients 
then begin to be more inconvenienced, owing to the discharge 
which obscures their vision, to sensations of weight in the lids and 
of foreign bodies in the eye, and to partial ptosis, which is often 
observable; and this, consequently, is generally the earliest stage 
at which we see the disease. The enlarged papillae often grow to 
a great size, completely hiding the granulations. In this stage the 
granulations may become absorbed, and the disease undergo cure ; 



no 



DISEASES OF THE EYE. 



but more commonly it makes further progress. Fresh granula- 
tions appear, while the old ones increase in size and undergo a 
peculiar gelatinous change. They then often become confluent, 
leaving only here and there an island of vascular mucous mem- 
brane. Sometimes the trachoma bodies are very small, and pre- 




Fig. 45 — (Saemisch). 
a, Muscle ; b b, Tarsus having undergone fatty degeneration ; c, Atro- 
phied Meibomian Gland ; d d, Hypertrophied Papilla ; e, Cicatricial Tissue 
in the conjunctiva; f, Tarsus. 



sent the appearances of minute white dots, and in this form they 
are not always easily found. 

These chronic granulations consist of lymph cells towards their 
surface, but towards their bases are formed chiefly of connective 
tissue. Gradually the cellular elements are transformed into con- 



THE CONJUNCTIVA. 



Ill 



nective tissue, or they may previously undergo the gelatinous 
change mentioned above, and in this way cicatricial degeneration 
of the conjunctiva is brought about at each spot where a granula- 
tion was seated. 

As the disease advances the submucous tissue becomes impli- 
cated in the connective tissue alterations, while the tarsus under- 
goes fatty degeneration and becomes hypertrophied. The granu- 
lations disappear, having reduced the conjunctiva more or less to 
a cicatrix. Contraction of the diseased conjunctiva on the inner 
surface of the lid causes entropion and distortion of the bulbs of 




Fig. 46. 



the eyelashes, followed by irregular growth of the latter, with re- 
sulting trichiasis and distichiasis. These changes are represented 
in Fig. 45. 

The great danger of granular ophthalmia lies in the complica- 
tions which may attend it or which follow in its wake ; the former 
consist in pannus, ulcers of the cornea, and severe purulent con- 
junctivitis, while the latter are the distortions of the lids and eye- 
lashes just referred to. 

Pannus (Lai., a cloth rag) presents the appearance (Fig. 46) 
of a superficial vascularization of the cornea, with more or less 
diffuse opacity, and often small infiltrations. It invariably com- 
mences in the upper portion of the cornea, extending generally over 
the upper half, and frequently remains confined to this region. But 
in many cases, at a later stage, it extends to the whole surface of 
the cornea ; and this latter occurrence often takes place almost 



2 DISEASES OF THE EYE. 

suddenly ; and the vascularization and opacity sometimes become 
so intense as to present quite a fleshy appearance, completely hid- 
ing the corresponding part of the iris from view. Histologically 
pannus consists of a new growth, which is extremely rich in cells, 
and which closely resembles the conjunctiva when occupied with 
confluent granulations. It is situated between the corneal epi- 
thelium and Bowman's layer, and is permeated by vessels derived 
from the conjunctival vessels. After a length of time Bowman's 
layer becomes destroyed in places, and then the cellular infiltration 
gains access to the true cornea, and gives rise to permanent changes 
in its transparency and curvature. In some bad cases of old- 
standing pannus the latter undergoes a connective-tissue change. 
It then becomes smooth on the surface, and the vessels almost dis- 
appear, so that the cornea is covered with a thin layer of connective 
tissue, which obstructs the passage of light and is not capable of 
cure. 

Another result of pannus, sometimes, is a bulging or staphylo- 
matous condition of the cornea, the tissues of which have become 
so altered that they give way before the normal intra-ocular tension. 

A pannus in which as yet there is no connective tissue altera- 
tion, and where there is no staphylomatous bulging, is capable of 
undergoing cure without leaving any opacity behind, except that 
which may be due to ulcers that have been present. 

Pannus is usually a painless affection, but is sometimes accom- 
panied by photophobia and ciliary neuralgia. It may come on at 
any stage of the disease, and causes defective vision, in propor- 
tion to the degree and extent of the opacity. Severe pannus is 
liable to induce iritis. 

The connection between pannus and the condition of the con- 
junctiva is not altogether evident. It was for long held that the 
corneal affection is due to mechanical irritation, caused by the 
rough palpebral conjunctiva; but this view is obviously incorrect, 
for severe pannus is often seen with a comparatively smooth con- 
junctiva, while with a truly rough conjunctiva the cornea is fre- 
quently perfectly clear. There can now be little doubt that pan- 
nus is analogous to the granular disease in the conjunctiva. It is, 
in fact, the same disease modified by reason of the different tissue 
in which it is situated, this different tissue being itself a modifica- 
tion of the conjunctiva; and it would seem probable that the 
cornea becomes diseased by direct inoculation from the conjunctiva 
of the upper lid. Yet it is remarkable that the bulbar conjunctiva, 



THE CONJUNCTIVA. 113 

lying between the upper margin of the cornea and the fornix of 
the upper hd, never becomes apparently diseased. 

Prognosis. — At any period prior to cicatrization of the con- 
junctiva an attack of purulent blennorrhea is liable to come on. 
If not too severe, this may result in a cure by absorption of the 
trachoma bodies, and should not be checked. If, however, the at- 
tack be very severe, the eye runs dangers similar to those of an 
ordinary attack of purulent conjunctivitis. These are less the 
more complete and the more intense the pannus. 

On the whole, if the disease come under care at an early period, 
and if treatment be carried out strictly, vision will be retained in a 
majority of cases, although a radical cure may be difficult or im- 
possible. These cases require to be under constant treatment for 
long periods, and the very lengthened time, and steady continuous 
treatment needed for a cure are probably the main obstacles to that 
cure. In most cases of chronic granular ophthalmia, attendance 
three times a week for a year will be required, to effect anything 
that can be called a cure. The common experience is that patients 
attend for some weeks, and then, being very considerably relieved 
of their distressing symptoms, and finding their sight vastly im- 
proved, they cease attendance long before the disease has been 
eliminated, to return after a brief interval with a condition of things 
as bad, if not worse, than before. It is therefore desirable at the 
very outset of treatment to explain the tedious and dangerous 
nature of the ailment to each patient. 

Treatment. — The aim of this is to bring about absorption of 
the trachoma bodies with the greatest possible dispatch, in order 
to prevent the destruction of the mucous membrane to which they 
tend. No caustic application should be made with the object of 
directly destroying the trachoma bodies, for this can only be done 
at the expense of the mucous membrane around them. For 
chronic cases, with little swelling of the papillae (blennorrhea), 
and with little or no cicatrization, the best application is the solid 
sulphate of copper lightly applied to the conjunctiva, especially at 
its fornix; but when there is considerable papillary swelling, a 
lo-grain solution of nitrate of silver, properly neutralized after 
its application with a solution of salt, or a light application of 
mitigated lapis, similarly neutralized, is to be preferred. Should 
there be ulcers on the cornea, or much inflammatory irritation 
of the eye, sulphate of copper should not be applied to the con- 
junctiva. An interval of twenty-four hours at least should be 

10 



114 DISEASES OF THE EYE. 

allowed to elapse between each application, whether of sulphate 
of copper or nitrate of silver, and cold sponging for fifteen 
minutes should be employed immediately after the application. 
A change of treatment will be occasionally required even if the 
remedy first used answer well in the beginning, and one or other 
of the following can be adopted : Pure carbolic acid liquefied has 
been used with good result, but I have no experience of it. It 
is applied with a camel's-hair pencil, and the excess washed off 
with plain water. Solution of Sublimate, i in 2000 to i in 1000, 
applied with lint or cotton-wool to the everted conjunctiva with 
some pressure and rubbing. Liq. plumb, acetatis dil., never to 
be used except with everted lids, and washed off with plain water 
by the surgeon ; and not even in this way if there be ulcers of the 
cornea, as the corneal tissue forming the floor of the ulcer is 
liable to become impregnated with a white deposit, probably the 
albuminate of lead, which is by no means easy to remove by 




Fig. 47. 



operation subsequently. Tannin ointment: Tannin gr. j, to 
vaselin 5j, the size of half a pea, to be put into the eye once 
a day. Sulphate of copper ointment: same strength as the last, 
and to be used in the same way. Solution of alum : Gr. x to §j 
of distilled water ; one drop in the eye once a day. Where an 
active pannus is present, a drop of solution of atropin should be 
instilled into the eye once a day as a precaution against iritis. 

Some employ scarifications of the conjunctiva when it is much 
swollen and the papillae too exuberant ; but I have never adopted 
them, fearing the resulting cicatrices. Brushing of the con- 
junctiva with a small stiff horsehair brush, or special metallic 
brush, is a form of scarification used by others, and is sometimes 
combined with applications of solution of sublimate ; and scraping 
of the conjunctiva with a sharp spoon, with subsequent rubbing in 
of corrosive sublimate solution, has been recommended. 

Again, it has been proposed to excise or abscise the trachoma 



THE CONJUNCTIVA. 115 

bodies ; and this may perhaps be allowable if they are isolated and 
protrude much over the surface of the conjunctiva. 

Squeezing out the granulations between the thumb-nails used 
to be practiced by the late Sir William Wilde, of Dublin, and has 
recently again come into use. But the proceeding of " expres- 
sion " is nowadays performed by means of an instrument instead 
of by the finger-nails. The best instrument for the purpose is 
Grady's trachoma forceps (Fig. 47). The retro-tarsal fold of 
the lower or upper lid is grasped as far back as possible by the 
instrument, compressed and drawn upon, and in this way the 
trachomatous tissue is squeezed out without laceration of the con- 
junctiva. The instrum.ent has to be re-inserted and a neighbor- 
ing part of the conjunctiva treated in the same way, and so on, 
until the whole conjunctiva of each affected eyelid has been oper- 
ated on. The four eyelids may be manipulated at one sitting, and 
the evacuation should be so complete that a repetition of the pro- 
ceeding will not be required. Particular care should be taken to 
reach the part of the conjunctiva which is hidden under the com- 
missures. Some cases are immediately and permanently cured 
by this operation ; while others, although greatly benefited, will 
still recjuire a further routine treatment with local remedies. Ex- 
pression is indicated only where trachomatous substance can be 
pressed out. J\Iy experience with this method leads me to regard 
it as a useful one for the acceleration of the cure of some 
cases of granular ophthalmia before the cicatricial stage has 
come on. 

Excision of the fornix conjunctivae has been proposed by 
Schneller,^ and largely practiced by him and other surgeons. It 
is claimed for this method that it shortens the treatment of all 
forms of the disease ; that, after it, existing corneal processes 
undergo rapid cure ; that the granular disease in the palpebral con- 
junctiva, although not directly included in the operation, disap- 
pears quickly ; that recurrences of the disease are rarer than by 
other plans of treatment ; and that the resulting linear cicatrix has 
no serious consequence, and is as nothing when compared with the 
extensive cicatricial degeneration of the whole mucous membrane 
which the operation is calculated to prevent. Supplemental treat- 
ment with the customary local applications is employed until the 
cure is obtained. I find that this is a useful procedure in some 
cases. 

Infusion of Jequirity {Arbus precatorius, Paternoster Bean), 



ii6 DISEASES OF THE EYE. 

long used in the Brazils, was introduced to the notice of Euro- 
pean surgeons by de Wecker. The infusion is made by macerating 
154 grains of the decorticized jequirity seeds in 16 oz. of cold 
water (a 3 per cent, infusion) for twenty-four hours. Twice a 
day for three days the lids are everted, and the infusion thoroughly 
rubbed into the conjunctiva with a sponge or bit of lint. The re- 
sult is a severe conjunctivitis of a somewhat croupous tendency 
(even the cornea being often hidden by the false membrane), ac- 
companied by great swelling of the eyelids, much pain, and con- 
siderable constitutional disturbance, rapid pulse, and temperature 
of 100°, or more. In the course of eight or ten days the inflamma- 
tion subsides, and the cornea in many cases will then be found to 
be free from pannus, or almost so, while complete cure of the 
granular ophthalmia itself is rarer. Iced compresses to the eye- 
lids should be used during the inflammation. A fresh infusion 
(not more than seven days old) must be employed in order to 
secure the best reaction. The majority of surgeons, amongst them 
myself, find the remedy harmless, if not always successful; but a 
good many cases are on record where violent diphtheritic conjunc- 
tivitis, followed by blennorrhea of the conjunctiva, and by more 
or less extensive ulceration of the cornea, and even complete loss 
of the eye, were produced. I have, two or three times, seen a small 
superficial ulcer form on the lower third of the cornea without 
further injury. De Wecker regards the presence of a purulent 
discharge from the conjunctiva as a contra-indication for the 
remedy, which he finds is then liable to increase the intensity of 
the blennorrhea in a dangerous degree. Cases where there is little 
or no papillary swelling, but nearly dry trachoma with pannus, 
are the most suitable for its use, and I cannot recommend it too 
highly in these cases. It is marvelous to see the rapid and beauti- 
ful cures of the severest pannus by this remedy in properly selected 
cases. But the presence of well-marked pannus of the cornea 
without ulceration is, I think, the only thing that can render the 
employment of jequirity justifiable, and in addition to this the 
conjunctiva should be free from blennorrhea. 

Freshly prepared finely pulverized jequirity beans, from which 
all oily matter has been removed, may be substituted for the infu- 
sion. It is flicked into the eye from a camel's-hair pencil, and is 
preferred by some to the infusion as being more easily managed 
in respect of dosage. 

Abrin, the active principle of the jequirity bean, has also been 



THE CONJUNCTIVA. 117 

proposed as a local application for trachoma,^ but it has not come 
into use owing to its highly toxic properties. 

The occurrence of acute dacryocystitis sometimes forms an un- 
pleasant complication of the jequirity treatment even in cases in 
which the sac was previously quite normal ; but I have never my- 
self seen it to occur. 

After the subsidence of the jequirity inflammation some of the 
local remedies above referred to should be regularly applied for 
the purpose of completing the cure of the conjunctival condition. 

Where pannus is present, an occasional drop of atropin should 
be instilled, in order to control the tendency to iritis. 

Besides local remedies, it is of great importance that the hy- 
gienic surroundings of patients suffering from granular ophthal- 
mia be seen to, and that they be obliged to spend a considerable 
time daily in the open air. 

If the upper lid be tightly pressed on the globe, as it sometimes 
is, the physiological pressure varying in different individuals, an 
impediment is offered to the cure by any method, and pannus is 
promoted. It is then necessary to relieve the pressure by a cantho- 
plastic operation. (See chap, vii.) 

Peritomy. — This procedure is adopted for the cure of pannus 
by destruction of the vessels which supply it, and is as follows : 
About 5 mm. from the margin of the cornea an incision is made 
in the conjunctiva with scissors, and carried at this distance all 
the way round the cornea. This ring of conjunctival tissue is 
then separated up from the sclerotic, and cut off at the corneal 
margin, and the underlying connective tissue is dissected off the 
corresponding portion of the sclerotic, which is thus laid quite bare. 
The proceeding is not always satisfactory, and of late years I have 
practiced it but little. 

Lymphoma of the Conjunctiva. — Under this heading cases 
have been described which present the appearances, at first sight, 
of acute granular ophthalmia ; but the " granulations," which are 
enormous in size, attack both lids, and are associated with enlarged 
lymphomatous masses in the neck, which do not lead to ulceration 
or scarring. The conjunctival affection runs a rapid and favor- 
able course, without any cicatricial contraction. 

Croupous Conjunctivitis. — This is a disease of early childhood, 
and is not common. The palpebral conjunctiva is a good deal 
swollen, and is covered with a false membrane, that may be peeled 
oft', leaving a mucous surface underneath, which bleeds little or 



ii8 DISEASES OF THE EYE. 

not at all. The disease is not a severe one, and does not cause 
secondary corneal affections, unless when the bulbar conjunctiva, 
as it very rarely does, participates in the attack. It must not be 
mistaken for diphtheritic conjunctivitis, from which it is readily 
distinguished by the ease with which in it the false membrane can 
be removed, and by the vascular condition of the underlying 
mucous membrane. 

This is usually regarded as nothing more than a severe form of 
catarrhal conjunctivitis, in which the secretion happens to be rich 
in fibrin, and hence possessed of a marked tendency to coagulate 
on the surface of the conjunctiva. But the presence of the Klebs- 
Loffler bacillus has been demonstrated in cases of croupous con- 
junctivitis, which ran a favorable course, and hence there seems 
to be a bacteriological relationship between this form of con- 
junctivitis and diphtheritic conjunctivitis, which are sO' different 
from each other clinically. 

Causes. — Contagion, Epidemic. 

Treatment. — Iced compresses or Leiter's tubes to the eyelids 
during the croupous stage, with antiseptic cleansing of the con- 
junctival sac (Sol. Hydrarg. Perchlor. i in 5000, or Sol. Acid. 
Borac. 4 per cent.). No caustic should be used in this stage, as 
it is apt to produce corneal changes. Sulphate of quinin sprinkled 
on the conjunctiva is praised by some surgeons as a useful applica- 
tion at this period. When the false membrane ceases to be formed 
a slight blennorrhea comes on ; and this is to be treated with nitrate 
of silver applications in the usual way. 

Diphtheritic Conjunctivitis. — There is no more serious ocu- 
lar disease than this, for it may destroy the eye in twenty-four 
hours ; while in severe cases treatment is almost powerless. For- 
utnately it is almost unknown in these countries, while in Berlin it 
used to be so frequent that von Graefe set apart two wards for it 
in his hospital, which were under my care as his assistant. It is 
now a much less common disease there, owing probably to the 
improved hygiene of the city. 

The subjective symptoms of its initial stage are similar, although 
severer, especially in the matter of pain, to those of blennorheic 
conjunctivitis. The objective symptoms differ from those of blen- 
norrhea, in that the lids are excessively stiff, owing to plastic in- 
filtration of the subepithelial and deeper layers of the conjunctiva, 
while the surface of the mucous membrane is smooth, and of a 
grayish or pale bluff color. If an attempt be made to peel off some 



THE CONJUNCTIVA. 119 

of the superficial exudation the surface underneath will be found 
of the same gray color, not red and vascular, as in croupous con- 
junctivitis. This stage of infiltration lasts from six to ten days, 
and constitutes the period of greatest peril to the eye ; for while 
it lasts the nutrition of the cornea must suffer, and sloughing 
of that organ is extremely apt to take place. Towards the close 
of the first stage the fibrinous infiltration is eliminated from 
the eyelids, and the conjunctiva gradually assumes a red and suc- 
culent appearance, and at the same time a purulent discharge is 
established. This constitutes the second or blennorrheic stage. A 
third stage is formed by cicatricial alterations in the mucous mem- 
brane, which often lead to symblepharon, or to xerophthalmos ; 
so that, even if the eye escape corneal dangers in the first and 
second stages, others almost as serious may await it in the final 
stage. 

Corneal complications are most likely to occur in the first stage, 
and are then also most likely to prove destructive to the eye. The 
earlier they appear the more dangerous are they. If the blennor- 
rheic stage come on before corneal complications appear, or even 
before an ulcer contracted in the first stage has advanced far, they 
are more easily controlled. 

Causes. — It is difficult to assign a cause for this disease, which 
chiefly attacks children. It is frequently epidemic, is extremely 
infectious, and, although similar in its nature, is rarely, if ever, 
found in connection with an attack of diphtheritis of the fauces. 
The Klebs-Loffler bacillus is always present in the conjunctival 
discharge. 

Treatment. — Injections of the anti-toxin serum are the sovereign 
remedy, but local applications are also of use. In the first stage 
frequent warm fomentations, with antiseptic cleansing, are the 
only local measures admissible. No caustic or astringent applica- 
tion should be used. Internally, the patient should be treated with 
iron and quinin and generous diet. In the second or blenorrheic 
stage careful caustic applications are to be used. Corneal ulcers 
must be dealt with, whenever they arise, in the same way as 
though the case were one of blennorrheic conjunctivitis. When 
the purulent discharge ceases, solutions of soda, milk, or glycerin 
may be prescribed as lotions for the conjunctiva, to arrest, if 
possible, the xerophthalmos. 

Conjunctival Complication of Smallpox. — Of this I have, for- 
tunately, too little experience to enable me to speak authoritatively. 



120 DISEASES OF THE EYE. 

The following embodies the views of the late Professor Horner,* 
who studied the subject during an epidemic in 1871. A good 
deal of uncertainty prevailed previously, for the initial stages of 
the eye affection w^ere not carefully observed by physicians, owing 
to the swelling of the eyelids, while the ophthalmologist saw only 
the results of the process in the period of convalescence. 

Smallpox pustules on the cornea are, Horner believed, ex- 
tremely rare; indeed, he saw but one such case. The most fre- 
quent and most serious mode of attack consists in a grayish-yellow 
infiltration in the conjunctiva close to the lower margin of the 
cornea, not extending to the fornix conjunctivae, nor far along 
the inner or outer margin of the cornea. It occurs in the eruptive 
stage, and is to be regarded clinically as a variola pustule. This 
infiltration or pustule gives rise to a corneal affection, as does a 
solitary marginal phlyctenula, either in the form of a marginal 
ulcer or as a deep purulent infiltration, ulcerating, perforating, 
leading to staphyloma, purulent irido-chorioiditis and panoph- 
thalmitis — results which are often first observed long after the 
primary conjunctival affection has disappeared. 

Horner believed that the germ of the conjunctival infiltration 
makes its w^ay between the eyelids, and that the constancy of the 
position of the infiltration below the cornea is accounted for by 
this theory, that part of the conjunctiva, with closed eyelids and 
eyeball conseciuently rotated upwards, being the most exposed to 
particles entering. 

Treatment. — On this ground he recommended the prophylactic 
use of boracic acid ointment on lint applied over the eyelids. If 
a conjunctival pustule have already formed without any, or only 
commencing, corneal affection, he w^ould destroy the pustule w^ith 
fresh chlorin water, or with mitigated lapis carefully neutralized. 
Corneal complications are treated as in blennorrhea of the con- 
junctiva or diphtheritis. 

The frequency with which the eyes become affected varies in 
different epidemics. 

As true post-variolous eye-affections, Horner recognized diffuse 
keratitis, iritis, and iridocyclitis, with opacities in the vitreous 
humor, and glaucoma ; in the hemorrhagic form of the disease, 
hemorrhages in the conjunctiva and retina ; and, where pyemic 
poisoning comes on, septic affections of the chorioid and of the 
retina take place. 

Amyloid Degeneration. — This rare disease attacks chiefly the 



THE CONJUNCTIVA. I2i 

palpebral conjunctiva, but is also seen in the bulbar portion. It 
causes great tumefaction of the affected lid, without any inflam- 
matory symptoms. The eyelid can be but partially elevated, and 
is often so stiff and hard that it can be everted only with diffi- 
culty. The conjunctiva has the appearance of white wax. The 
disease ultimately extends to the tarsus, but is a strictly localized 
process, and not associated with amyloid disease in any other part 
of the system. It sometimes seems to be developed from granu- 
lar ophthalmia, but occurs also as a primary disease. The positive 
diagnosis can be made by submitting a small portion of the diseased 
conjunctiva to the iodin test. 

Hyaline Degeneration of the conjunctiva has also been observed. 
It cannot clinically be distinguished from Amyloid Degeneration, 
and is really an early state of the latter condition. 

Treatment consists in the removal of the diseased parts, by the 
knife and scraping, so far as may be possible. 

Tubercular Disease of the Conjunctiva. — This is an ex- 
tremely rare disease. It usually commences in the palpebral con- 
junctiva of the upper lid, and very rarely in the bulbar conjunctiva, 
in the form of small round yellowish-gray nodules, which soon 
ulcerate. The margins of these ulcers are well defined, and their 
floors either of a yellowish lardaceous appearance, or covered with 
grayish-red granulations. The surrounding conjunctiva is swol- 
len, and if the palpebral conjunctiva be much involved the lid be- 
comes enlarged in every dimension, and the ulcerative process 
may soon destroy part of the lid. It may also extend to the bulbar 
conjunctiva, and the cornea may become covered with pannus. 
The preauricular and submaxillary glands usually become en- 
larged. The positive diagnosis of the nature of the disease should 
be made by the examination of portions of the floor of the ulcer 
for the characteristic tubercle bacillus, which will distinguish this 
from secondary syphilitic ulceration of the conjunctiva, between 
which and the tubercular ulceration there is sometimes a resem- 
blance. The appearance may also be suggestive of trachoma, or 
even of a malignant growth. Tubercular conjunctival disease is 
usually unattended by pain, or there is only a slight burning sensa- 
tion ; but, again, when the ulceration is extensive, severe pain may 
set in. 

The disease is very chronic, its progress sometimes extending 
over many years. It is rarely met with except in youth. Some 
of those whose eyes are attacked are already the subjects of tuber- 



122 DISEASES OF THE EYE. 

culosis in other organs, but very many of them are perfectly 
healthy in that respect. In fact, we have reason to believe that 
tuberculosis of the conjunctiva is much more often a primary dis- 
ease, the result of an ectogenic infection, even in cases where al- 
ready tuberculosis exists elsewhere, than of infection occurring 
through the blood. Tubercle bacilli introduced into the normal 
conjunctival sac have, it is true, been found to be harmless, for 
the intact epithelium offers an insuperable obstacle to their en- 
trance into the tissue. But a superficial loss of substance of the 
conjunctiva is sufficient to allow of its inoculation with the bacilli, 
and then the disease becomes established. The frequent lodg- 
ment of foreign bodies under the upper lid explains why this is 
the most common place for the disease to begin in. But although 
conjunctival tubercular disease is not often secondary to tuber- 
cular disease in other parts of the system, yet it is itself liable to 
be the starting-point of general tuberculosis. 

Treatment. — The fact last mentioned makes it most important, 
in cases of primary tubercular disease of the conjunctiva, to 
thoroughly eradicate the diseased focus so as to avert an infection 
of other organs, and this can often be effected. If the ulcers be 
not already too extensive they must be scraped, and the actual 
cautery freely applied to them ; and, where the disease has al- 
ready spread to the cornea, sclerotic, iris, or chorioid, enucleation 
of the eyeball is imperatively called for. 

Lupus of the conjunctiva usually occurs as an extension of 
the disease from the surrounding skin, or rarely from the lacrimal 
sac, as in a case of Dr. Louis Werner's, where the disease extended 
from the mucous membrane of the nose, through both lacrimal 
sacs, to the inferior palpebral conjunctiva. It is seen as a patch or 
patches of ulceration, covered with small dark-red protuberances 
or granulations, chiefly on the palpebral conjunctiva, which bleed 
easily on being touched. 

Like lupus of the skin, these ulcerations undergo spontaneous 
healing and cicatrization in one place (unlike tubercular ulcera- 
tion in that respect), while they are still creeping over the surface 
in another direction. But we now know that lupus, wherever it 
occurs, is really a tubercular disease, and that the two forms differ 
only in their clinical aspect. 

The Treatment is scraping with a sharp spoon and the applica- 
tion of the actual cautery. 

Pemphigus of the Conjunctiva. — This is another rare disease. 



THE CONJUNCTIVA. 123 

It has been seen in connection with pemphigus vulgaris of other 
parts of the body, but it also occurs as an independent disease. It 
is attended by attacks of much pain, photophobia, and lacrimation ; 
and the conjunctiva, at each place where subconjunctival exudation 
of serum has been situated, undergoes degeneration and cicatricial 
contraction. Such attacks succeed each other at shorter or longer 
intervals, for weeks, months, or years, until, finally, the entire 
conjunctiva of each eye may have become destroyed, and the eye- 
lids are adherent to the eyeball. The cornea gradually becomes 
completely opaque, or, having ulcerated, becomes staphylomatous. 
In the course of the disease the eyelashes are apt to become turned 
in on the eyeball, or even entropion may form ; and these condi- 
tions aggravate the suffering of the patient. 

The foregoing is a description of a severe case. In less severe 
cases the conjunctiva may not be completely destroyed, and the 
cornea may not be affected. 

The formation of a true bulla hardly ever occurs, for the con- 
junctival epithelium is so delicate that it cannot be disturbed in 
this way by the serous exudation beneath it, but rather breaks 
down at once. Consequently, the conjunctival surface is found 
in these cases to be covered by what looks like a membranous 
deposit, upon removal of which a raw surface is exposed ; and 
these appearances have led to the mistaken diagnosis of croupous 
and of diphtheritic conjunctivitis. 

Treatment is helpless in respect of arresting the progress of 
the disease, or of restoring sight when lost in consequence of 
it. The most one can do is to relieve the distressing symptoms 
by emollients to the conjunctiva, and by the use of closely fitting 
goggles, to protect from wnnd, dust, and sun. Internally, arsenic 
is indicated. 

Xerosis {^rjpo?^ dry), or Xerophthalmos is a dry, lusterless 
condition of the conjunctiva, associated in the severer forms with 
shrinking of the membrane. There are two forms of the affection 
— the parenchymatous and the epithelial. 

In Parenchymatous Xerophthalmos there is a more or less ex- 
tensive cicatricial degeneration of the conjunctiva, dependent 
upon changes in its deeper layers, while its surface and that of 
the cornea become dry, and the latter becomes opaque, and the eye 
consequently sightless. The conjunctiva shrinks so completely in 
many of these cases that both lids are found adherent in their 
whole extent to the eyeball, which is exposed merely at the 



124 



DISEASES OF THE EYE. 



palpebral fissure, where the opaque and lustreless cornea is to be 
seen. From what remains of the conjunctiva, scales, composed of 
dry epithelium, fat, etc., peel away. The motions of the eyeball 
are restricted in proportion to the extent of the conjunctival de- 
generation. There is no cure for this condition. 

Fig. 48 represents a case of xerophthalmos, the result of pemphi- 
gus, which was under my care at the Royal Victoria Eye and Ear 




Fig. 48. 



Hospital. Here the eyelids were not wholly adherent to the eye- 
ball, and the cornea remained clear. 

The Causes of parenchymatous xerosis of the conjunctiva are 
granular ophthalmia, diphtheritic ophthalmia, pemphigus, and the 
condition is said to be very occasionally seen as a primary disease, 
described as essential shrinking of the conjunctiva. Many ob- 
servers altogether deny the existence of the primary affection, and 
maintain that the cases described as being of that nature are 
merely the result of pemphigus, and I am inclined to agree with 
this view. 

Treatment. — As cure is impossible in this form of xerophthal- 
mos, the only indication is to afford relief, so far as it can be done, 



THE CONJUNCTIVA. 125 

from the distressing sensations of dryness of the eyes which are 
complained of. The best appHcations are milk, glycerin, olive oil, 
and weak alkaline solutions, and the eyes should be protected from 
all irritating influences by protection goggles. 

Epithelial Xerosis of the conjunctiva is confined to the epithelium 
of that part of the conjunctiva which covers the exposed portion 
of the sclerotic in the palpebral opening. It there becomes dry 
and dull and covered with small white spots ; while the whole bulbar 
conjunctiva is loose, and easily thrown into folds by motions of 
the eyeball, and there may be a good deal of secretion. This form 
of xerophthalmos often occurs in epidemics, but also sporadically, 
accompanied, oddly enough, by night-blindness (the light-sense 
unimpaired) and contraction of the field of vision. The combined 
condition has been noticed chiefly in persons of debilitated con- 
stitution, who have been exposed to strong glares of light, and is 
said to have appeared in epidemics, under these conditions, in for- 
eign prisons and barracks. 

Treatment by rest, protection from glare of light, nutritious 
diet, and tonics invariably restore the eyes to their normal func- 
tions. 

Again, epithelial xerosis occurs in very young children in con- 
nection with a destructive ulceration of the cornea (see Infantile 
Ulceration of the Cornea with Xerosis of the Conjunctiva, chap. 

vi.). 

Pterygium {nrepv^, a wing). — This is a vascularized thicken- 
ing of the conjunctiva, triangular in shape, situated most usually 
to the inside of the cornea, sometimes to its outer side, and rarely 
either above or below it. The apex of the triangle, the head of the 
pterygium, is on the cornea; and its base, the body, at the semi- 
lunar fold. The neck of the pterygium is that part of it at the 
margin of the cornea. There is frequently, but not always, a 
tendency of the growth to advance into the cornea, of which it 
seldom reaches the center, and still more rarely extends quite" 
across it. 

In its early growth the pterygium is somewhat thick and suc- 
culent-looking, and very vascular. But finally it ceases to grow, 
and then becomes thm and pale, and this is its retrogressive stage ; 
yet it never entirely disappears. Sight is not affected unless the 
pterygium extends over the pupillary region of the cornea. A 
limitation of the motion of the eye to the other side, and conse- 
quent diplopia, is sometimes caused by a pterygium; but, for the 



126 DISEASES OF THE EYE. 

most part, the disfigurement alone it is which brings these cases to 
the surgeon. 

Causes. — The starting-point of a pterygium is often an ulcer 
at the margin of the cornea, which in healing catches a morsel of 
the limbus conjunctivae and draws it towards the cicatrix, throw- 
ing the mucous membrane into a triangular fold. The ulcer then 
forms anew in the cornea immediately inside the cicatrix, and, in 
healing, the point of conjunctiva is drawn into it again, and is 
carried a little farther into the cornea, and so on. The hollow 
lying between a pinguecula (see below) and the margin of the 
cornea is apt to lodge small foreign bodies, which cause shallow 
marginal ulcers, and these, in healing, draw the pinguecula over 
on the cornea. A marginal ulcer in phlyctenular keratitis, or in 
acute blennorrhea, may serve the same end. The only objection 
to this theory of the causation of pterygium is that an ulcer is not 
always to be found at the head of the growth. 

Fuchs ^° believes that pterygium develops from the pinguecula, 
and that the latter causes nutritive changes in the cornea, loosening 
the superficial lamellae, and allowing the connective tissue of the 
limbus to grow in on the cornea. 

Pterygium is a rare affection in this country, but is more com- 
mon in countries or localities where the air is filled with fine sand 
or other minute particles. 

Treatment. — Unless the pterygium be very thick, and have in- 
vaded the cornea to some extent, or be progressing over the cornea, 
it is well to let it alone ; the more so as by removing it a quite 
normal appearance is not given to the eye, for a mark is neces- 
sarily left both on cornea and conjunctiva. If it be progressive 
or very disfiguring, it should be removed, other proposed modes 
of dealing with it being futile. This may be effected either by 
ligature or excision. 

In the method by ligature a strong silk suture is passed through 
two needles. The pterygium being raised with a forceps close to 
the cornea, one needle is passed under it here and the other needle 
in the same way close to its base, the ligature being drawn half- 
way through. The thread is cut close behind each needle, thus 
forming three ligatures, which are respectively tied tight. In four 
or five days the pterygium comes away. 

For excision the apex is seized with a forceps and dissected ofif 
either with a scissors or fine scalpel, care being taken not to injure 
the true cornea ; or a good plan is to pass a strabismus hook under 



THE CONJUNCTIVA. 127 

the pterygium when raised up from the sclerotic, and to forcibly 
separate the corneal portion by drawing the hook under it. The 
dissection is continued towards the base of the pterygium, where 
it is finished with two convergent incisions meeting at the base. 
The mucous membrane in the neighborhood of the base is separated 
up somewhat from the sclerotic, and the margins of the con- 
junctival wound are then carefully brought together with sutures. 
Skin grafts, according to Thiersch's method, have been used with 
success to cover the defect. 

Pinguecula (pinguis, fat) is the name given to a small yellow- 
ish elevation in the conjunctiva near the margin of the cornea, 
usually at its inner side, more rarely at its temporal margin, but 
sometimes in each place. It contains, notwithstanding its name, 
no fat, but is composed of connective tissue and elastic fibers. It 
is supposed to be due to the irritation caused by small foreign 
bodies. It rarely grows to a large size, and requires no treatment 
unless it becomes very disfiguring, when it may be removed with 
forceps and scissors. 

Subconjunctival Ecchymosis. — The rupture of a small sub- 
conjunctival vessel in the bulbar conjunctiva, without conjuncti- 
vitis, is of frequent occurrence. It suddenly gives a more or less 
extensive purple hue to the " white of the eye," causing the pa- 
tient much concern. It is common enough in old people, but may 
occur in the young, and even in children, from severe straining, 
as in whooping-cough, vomiting, or raising heavy weights. It is 
occasionally significant of diabetes. It also occurs sometimes dur- 
ing epileptic fits, and profuse subconjunctival hemorrhage is oc- 
casionally found in cases of fracture of the base of the skull, having 
made its way along the floor of the orbit. It is of no importance 
so far as the integrity of the eye is concerned. 

Treatment. — None is required, the extravasated blood gradually 
becoming absorbed. 

Nevus of the conjunctiva may occur along with the same con- 
dition of the lids, but it also occurs separately, especially on the 
plica or caruncle. 

Treatment. — Electrolysis or ligature. Good results have been 
obtained by Snell ^^ with ethylate of sodium carefully painted 
on. 

Polypus of the conjunctiva, for which it is difficult to assign 
a cause, is sometimes seen. It is generally small, in connection 
with the semilunar fold or caruncle, and can readily be removed 



128 DISEASES OF THE EYE. 

with the scissors. Granulations occurring after tenotomy for 
strabismus are sometimes, and incorrectly, called polypi. 

Dermoid Tumors. — These are pale yellow in color, and in size 
from that of a split pea to that of a cherry. They are smooth on 
the surface, and sometimes have fine hairs, and sit usually at the 
outer and lower margin of the cornea; but Fig. 49 was drawn 
from a case on which I operated, where the dermoid was situated 
on the inner side of the cornea, extending over somewhat on the 
latter, and not at the most usual seat. In structure they resemble 
that of the skin. They are congenital tumors, supposed to be 
due to an arrest in development, but they often have a tendency 
to extend over the cornea. If this tendency be present, the tumor 



Fig. 49. 

must be removed by dissecting it off the cornea, care being taken 
not to go into the deep layers of the latter. 

Lipoma occurs as a congenital subconjunctival formation of 
fat, usually situated between the superior and external recti 
muscles. 

Syphilitic Disease of the Conjunctiva occurs both as primary 
and as secondary disease. It will be treated of in chap. vi. on Dis- 
eases of the Eyelids. 

Papilloma, or Papillary Fibroma. — This is a non-malignant 
growth, which may spring from any part of the conjunctival sac. 
It appears in the beginning as a small round red knob. The papil- 
lomata growing from the tarsal conjunctiva and from the semi- 
lunar fold frequently take on a cauliflower appearance ; while on 
the bulbar conjunctiva and in the fornix the growths are liable to 
be pedunculated, with a papillary surface. The limbus of the con- 
junctiva is a favorite seat for a papilloma, and in the early stage 



THE CONJUNCTIVA. 129 

it may be impossible to distinguish it from an epithelioma. But 
if the case come under observation at a later stage, when the 
growth has overlapped the cornea, this difficulty does not arise ; 
for the papilloma merely lies on the cornea, and can be lifted 
freely off it with a probe, while epithelioma infiltrates the corneal 
tissue. 

Treatment. — Thorough removal with knife or scissors, and 
actual cautery, as otherwise the growth is liable to recur. 

Epithelioma is not common as a primary disease of the con- 
junctiva. When it is so found it is seen as a little non-pigmented 
tumor growing from the limbus of the conjunctiva, surrounded 
by vascularization, and may in this stage be mistaken for a 
phlyctenula — of which, however, the margins are not so steep — 
or for a papilloma (z'ide supra). As the tumor increases in size 
it becomes lobulated, and ulcerates, and soon attacks the cornea, 
giving rise on the latter to an appearance very like pannus. The 
neighboring lymphatic glands become enlarged. 

Sarcoma, too, is rare. It likewise most commonly takes its 
origin in the limbus conjunctivae, and is then usually a pigmented 
tumor, a melanosarcoma. That these sarcomata are pigmented is 
explained by the fact that the limbus contains pigment, although 
so slight in amount as not to be visible to the naked eye. The 
growth spreads backwards over the sclerotic, with which it becomes 
loosely adherent. It does not attack the cornea so readily as the 
epitheliomatous growths, although it often overlaps the surface of 
the cornea. In some cases it burrows under Bowman's layer, and 
gradually into the deep layers of the cornea, and by this path 
reaches the interior of the eyeball. In its later stages this tumor 
grows to an enormous size. 

But conjunctival sarcoma also starts from other parts of the 
conjunctiva, and in a case of my own I four times removed sar- 
comatous tumors from different parts of the fornix, an interval 
of some months elapsing between the appearance of each small 
tumor. 

Treatment. — Both epithelioma and sarcoma of the conjunctiva 
demand prompt operative removal in order to prevent an extension 
of the growth to the rest of the eye, if the case be seen early, as 
well as to avert metastases to other organs. The knife and actual 
cautery may save the eye, and the life in the early stages, but later 
on removal of the whole eye is often called for. 

Simple Cysts of the conjunctiva are very rare. They appear 

SI 



I30 DISEASES OF THE EYE. 

as clearly spherical protuberances of about the size of a pea, seated 
usually on the bulbar conjunctiva. The walls of the cysts contain 
but few vessels, are thin, and almost transparent; while for con- 
tents they have a clear limpid fluid. These cysts cannot as a rule 
be moved from their position, because they are adherent to the 
conjunctiva, which indeed takes part in the formation of their 
walls. They are, very probably, dilated lymphatic vessels. Small 
beadlike strings of dilated lymphatics are very frequently seen on 
the bulbar conjunctiva. 

These simple cysts are most commonly congenital, but they may 
begin to be developed during life. 

Treatment. — The cyst may be dissected out, or it may be suffi- 
cient to abscise its anterior wall. 

Subconjunctival Cysticercus is a little more common than 
simple cyst of the conjunctiva, and yet only about fifty examples 
of it have been recorded. 

Cysticerus is distinguished from simple cyst by its free mo- 
bility under the conjunctiva, to which it is not attached; by its 
thicker and more vascular walls ; and, above all, by the presence 
of a round, white, opaque spot on the anterior surface, first pointed 
out by Sichel, and looked on by him as pathognomonic of a cys- 
ticercus. This spot indicates the position of the receptaculum ; 
and occasionally, when this comes to be placed on the posterior 
surface of the cyst, it may be difficult, or impossible, to make the 
diagnosis with certainty. 

Treatment. — The cyst may be pushed to one side under the con- 
junctiva, an incision made in the latter, the cyst then pushed back 
again, and out through the opening. 

Lithiasis consists in the calcification of the secretion of the 
Meibomian glands, which are seen as little brilliantly white spots 
not larger than a pin's head in the conjunctiva. There may 
be one only or very many. These concretions often give rise to 
much conjunctival irritation, and if they protrude over the surface 
of the conjunctiva may injure the cornea. Each one — the eye 
having been cocainized — must be separately removed by a needle, 
with which first an incision has been made into the conjunctiva 
over the concretion. 

Conjunctivitis Petrificans. — Under this title Leber ^^ has de- 
scribed a rare and remarkable disease of the conjunctiva. In the 
course of a brief period, and accompanied by some slight inflam- 
matory reaction, a stony hard, white, chalky substance is deposited, 



THE CONJUNCTIVA. 131 

in more or less extensive patches, in the previously healthy con- 
junctiva, the deposit being scarcely raised over the conjunctival 
surface. The disease attacks a part of the bulbar or palpebral 
conjunctiva, and may extend to the intermarginal portion of the 
eyelid. One or both eyes may be attacked. After a time, which 
varies from a week to several months, the deposit is thrown off 
or absorbed, and the affected part suffers either no detriment or 
there may be slight thickening and shrinking. There is no great 
tendency to corneal complications, but slight marginal ulcerations, 
which heal readily, occasionally occur. In one case severe diffuse 
opacity of the cornea seriously affected the sight. Frequent re- 
lapses are liable to take place in the same or in different parts of 
the conjunctiva, and the whole course of the affection may extend 
over several years, and then end in complete cure. 

No cause has as yet been assigned for this disease, although 
Leber suspects it to be an ectogenic microbic infection. The only 
treatment which seems to be of use is warm fomentations, and the 
careful operative removal from time to time of the chalky scales 
as they become loosened from the main mass. 

Uric Acid Deposits have been seen in the palpebral con- 
junctiva in gouty cases. 

Injuries of the Conjunctiva. — Foreign bodies frequently make 
their way into the conjunctival sac, and cause much pain, espe- 
cially if they get under the upper lid, by reason, chiefly, of their 
coming in contact with the corneal surface during motions of the 
lid and of the eye. If the foreign body be under the lower lid it 
will be easily found on drawing down the latter, and, provided it 
be not actually embedded in the mucous membrane, it is easily re- 
moved with a camel's-hair pencil or with the corner of a soft 
pocket-handkerchief; but if the foreign body be under the upper 
lid it is necessary to evert the latter before it is reached. Should 
the foreign body be embedded in the conjunctiva it must be 
pricked out of its position with the point of a needle or other suit- 
able instrument. 

The conjunctiva is frequently injured in severe wounds of the 
eyelids or eyeball. The interest and treatment are centered here 
chiefly on the other more important parts, which have been in- 
jured. A tear or wound of the conjunctiva (usually of the bulbar 
portion), when it occasionally occurs without injury to other parts, 
is in general of very slight moment. If the wound be extensive 
its edges should be drawn together with a few points of suture; 



132 DISEASES OF THE EYE 

but otherwise healing will take place with the aid simply of a 
bandage to keep the eye closed for a few days. 

A common form of injury, which may involve the conjunctiva 
alone, is a burn by acid or lime. In the case of ^, strong acid get- 
ting into the eye, if the patient be seen immediately after the 
occurrence, the whole conjunctival sac should be well washed out 
with an alkaline solution (i per cent, soda solution). In the case 
of lime, after all the particles have been most carefully removed 
from the eye with forceps, a weak solution of a mineral acid may 
be used for washing out the conjunctival sac ; or, as is recom- 
mended by some, a solution of sugar as thick as syrup may be 
poured into the eye. Later, olive or castor oil, or even butter, may 
be applied, the subsequent treatment being continued with weak 
sublimate ointment. Cocain may be employed to relieve the pain. 

In the case of a severe burn of the conjunctiva, the resulting 
cicatrix is liable to produce a more or less extensive union of the 
eyelid to the eyeball (Symblepharon), which often interferes with 
the motion of the latter, or even with vision, if the cornea be ob- 
scured. No measures taken during the healing process can pre- 
vent symblepharon if the degree of the burn be such as to bring it 
about. The relief of symblepharon by operation will be dealt with 
in chap, vi., on Diseases of the Eyelids. 

References. 



1 << 



Von Graefe's Archiv," xlviii. p. 639. 
^ " Annales d'Oculistique," Janvier, 1897. 

' " Bericht der ophthalmologischen Gesellschaft." Heidelberg, 1897, 
p. 249- 

* Gerhardt's " Handbuch der Kinderkrankheiten," V. Part 2. 
°" Archiv fiir Ophthalmologie," xxxvi. i, p. 109. 

* *' Bericht der ophthalmologischen Gesellschaft." Heidelberg, 1896, p. 
156. 

^ " Annales d'Oculistique," 1894, p. 19. 

® " Von Graefe's Archiv," xxx. 4. p. 131; and xxxiii. p. 113. 
' Ibidem, Hi. i. p. 72. 
^° Ibidem, xxxviii. 2. p. i. 

" " Trans. Ophthal. Society of the United Kingdom," xiii. p. 39. 
" " Bericht der ophthalmologischen Gesellschaft." Heidelberg, 1895, 
p. 46; and "Von Graefe's Archiv," li. i. p. i. 



CHAPTER V. 

PHLYCTENULAR, OR STRUMOUS, CONJUNCTI- 
VITIS KERATITIS.* 

Both from a clinical and nosological point of view it would be 
incorrect to divide this affection into two, under the heads of Dis- 
eases of the Conjunctiva and Diseases of the Cornea ; and there- 
fore I treat of it here as one disease, and, being a very important 
disease, I devote a special chapter to it. It is important, because 
it is excessively common, and because it is capable of causing con- 
siderable damage to sight. Moreover, even when it occurs on the 
cornea, it might, strictly speaking, be regarded as a conjunctival 
disease, for that corneal layer, which it primarily attacks, is the 
epithelium, and this — and probably also Bowman's membrane and 
the anterior layers of the true cornea — as we know from the fetal 
development of the membrane, is a continuation of the conjunctiva 
in a modified form over the cornea. "j" 

The disease is characterized by the eruption of phlyctenulae 
{cpXvnraiva^ a vesicle, or piistitle) on the conjunctiva bulbi, on 
the conjunctival limbus, or on the cornea, and, if the upper lid be 
everted, small phlyctenular ulcers will not rarely be found on the 
tarsal conjunctiva. It is chiefly a disease of children up to the 
eighth or tenth year of age. 

Notwithstanding the derivation of the word, a phlyctenula, or 
phlyctene, is originally neither a vesicle nor a pustule. It is a 
formation sui generis, and, when on the conjunctiva, is a solid ele- 
vation consisting of a collection of lymph cells, and is of a grayish 
color. In a late stage the phlyctenula, especially on the cornea, 
may become a pustule by infection. On the conjunctiva two types 
of the disease can be recognized : 

I The Solitary, or Simple, Phlyctenula. — Of this there 

* Kepac, a horn. 

t The posterior epithelium — or, according to some, this along with the 
membrane of Descemet and the posterior layers of the true cornea — is to 
be reckoned to the uveal tract; while the true cornea is a modification of 
the sclerotic. 

133 



134 DISEASES OF THE EYE. 

may be one or several, varying in size from i mm. to 4 mm. in 
diameter. The vascular injection is immediately around the 
phlyctenula, and is not diffused over the conjunctiva. At first 
there may be shooting pains and lacrimation, but these soon pass 
away. If the phlyctenulse be not seated close to the cornea the 
affection is not serious ; and the length of time required for its 
cure depends on the size of the phlyctenulse, varying from seven 
to fourteen days, as a rule. 

2. Multiple, or Miliary, Phlyctenulae. — These are very mi- 
nute, like grains of fine sand, and are always situated on the limbus 
of the conjunctiva, which is swelled. The general injection and 
swelling of the conjunctiva are considerable; and, occurring as it 
does almost exclusively in young children, the affection may be 
called Eczematous Conjunctival Catarrh of Children (Horner). 
The irritation and so-called photophobia and lacrimation are often 
considerable, and there is a good deal of conjiinctival discharge. 
This form is very apt to appear after measles and scarlatina. 

Both forms are liable to extend to the cornea, and then only does 
the disease become serious. This event may come about in the 
following different ways : 

The Solitary Phlyctenula may be seated partly on the limbus 
conjunctivae and partly on the margin of the cornea, and may 
undergo resolution. 

Or it may give rise to a deep ulcer, which either heals, leaving 
a scar, or perforates, causing prolapse of the iris, etc. 

Or it may form the starting-point of a progressive riband-like 
keratitis (Fascicular Keratitis), the pustule becoming an ulcer, at 
the margin of which the corneal epithelium is raised and infiltrated 
in crescentic shape. This now steadily advances for many weeks 
towards the center of the cornea, followed by a leash of vessels 
which has its termination in the concavity of the crescent. The 
process is accompanied by much irritation of the terminal branches 
of the fifth nerve in the cornea, and the consequent reflex blepharo- 
spasm. A permanent mark indicates the track of the ulcer. 

The Multiple Miliary Phlyctenulse on the limbus conjunctivae 
may cause some slight superficial infiltration and vascularization 
of the cornea in their immediate neighborhood, which pass off 
when the phlyctenulae disappear. 

Or they may be accompanied by deeper marginal infiltrations of 
the cornea, which become confluent and result in an ulcer that ex- 
tends along the margin of the cornea for some distance, and is 



PHLYCTENULAR OPHTHALMIA. 



135 



termed a Ring Ulcer. It is a serious form of ulcer; for if it ex- 
tends far round it may destroy the cornea in a few days by cutting 
of¥ its nutrition. 

Primary Phlyctenular Keratitis occurs principally in three 
different forms : ( i ) \>ry small gray subepithelial infiltrations, 
which are apt to turn into small ulcers, and then heal, leaving a 
slight mark. This mark may ultimately quite disappear, espe- 
cially in the case of children, and when situated peripherically. 
(2) Somewhat larger and deeper infiltrations, resulting in ulcers 
of corresponding size, which heal by aid of vascularization from 
the margin of the cornea. The opacity left after these ulcers is 




Fig. 50. — E, Epithelium ; B, Ant. elastic Lamina ; C, True Cornea ; N, 
Nerve Filament, with Lymph Cells on its course ; D, Phlyctenula. 

rather intense, and clears up but little, especially if the situation 
be central. (3) Large and deep-seated pustules, often at the 
center of the cornea, giving rise to large and deep ulcers, which 
may be accompanied by hypopyon and even by iritis, and which 
frequently go on to perforation. 

Photophobia is usually a prominent symptom in phlyctenular 
keratitis. The term photophobia, however, is not altogether cor- 
rect, for it is the fifth nerve (from the cornea) which is mainly 
the afferent nerve here rather than the optic nerve. This is evi- 
dent from the fact that in the dark the patient does not get com- 
plete relief. The explanation of this reflex blepharospasm has 
been given by Iwanoff,^ who showed that the round cells, in mak- 
ing their way from the margin of the cornea to their position under 



136 DISEASES OF THE EYE. 

the epithelium, follow the course of the nerve filaments, which 
they irritate in their progress. The accompanying Figs. 50 and 
51 are from his original paper. 

Eczema of the eyelids, face, and external ear, and catarrh of 
the Schneiderian mucous membrane, frequently accompany phlyc- 
tenular conjunctivitis and keratitis. 

In these cases, in children of three or four years of age, tem- 
porary amaurosis has sometimes been observed after a severe and 
long-continued blepharospasm has passed away. The patient is 
found to be unable to see even large objects, or to find his way, 
although the pupil reflex is active, and a strong light may still be 
distressing. There are no ophthalmoscopic appearances. This 
blindness passes away completely, usually in from two to four 



^-v 



weeks, although the interval before recovery of sight may be sev- 
eral months. A certain mental dullness, which also ultimately 
disappears, is noticed in some cases. This temporary loss of 
sight has been regarded as a reflex phenomenon, and again it has 
been held to be due to disturbance of the intra-ocular circulation 
from pressure of the eyelids on the eyeball. But the view (Leber, 
Uhthoff) which represents it as having a cerebral origin of a func- 
tional nature is probably the correct one. It is likely at this ten- 
der age, when the psycho-physical processes are not as yet firmly 
established, that the desire not to see, and the active withdrawal 
from the act of vision, leads in a short time to a functional paralysis 
of the visual centers in the brain, and that these take some time 
to recover or to re-learn their functions when the ground for the 
suspension of the latter has ceased. 

Cause.— This is a disease of childhood, although it is rare in the 
very first year of life. In adults it is uncommon. 



PHLYCTENULAR OPHTHALMIA. 137 

The strumous constitution, as indicated by the swollen nose and 
upper lip and sometimes by the enlarged lymphatics in the neck, 
as well as by the eczema just mentioned, is that most liable to this 
affection. Often, however, it will be found in strong children 
with apparently perfect general health ; but even in them there is 
probably some allied irregularity of nutrition, of which the great 
tendency to recurrence of the eye affection is evidence. 

Colonies of straw-colored micrococci may be found in the con- 
tents of the phlyctenulae ; but what etiological relationship, if any, 
to the production of the phlyctenulae they possess is not yet 
known. 

Treatment. — The solitary phlyctenula is best treated with the 
yellow oxid of mercury ointment in the strength of 10 grs. to §j 
of benzoated lard or vaselin, of which the size of a hemp-seed 
should be put into the eye once a day. Or a small quantity of pure 
calomel dusted into the eye once a day will also cure; but this 
remedy should not be employed if iodid of potassium is being taken 
internally, for then iodid of mercury is liable to be formed in the 
conjunctiva. 

The miliary phylctenular conjunctivitis is best treated at first 
with cold or iced applications. Freshly prepared chlorin water 
(i part Liq. Chlori., 9 parts water), to be dropped into the eye 
once a day, is recommended by some, and later on Liq. plumbi dil. 
or Sol. argent, nitr. (grs. v ad oj, and neutralized) appHed to the 
everted conjunctiva ; or, if the phlyctenular appearance predomi- 
nate over the catarrhal, the yellow oxid of mercury ointment or in- 
sufflations of calomel may be preferred. I myself rarely employ 
any remedy other than the two latter, which I find applicable to all 
these cases. 

When the cornea is slightly affected near the margin in cases of 
miliary phlyctenulae, calomel, or the yellow oxid of mercury oint- 
ment, and warm fomentations, should be used. 

Where a large pustule on the margin of the cornea has resulted 

in a deep ulcer, with tendency to perforate, and accompanied by 

much pain, I cannot too highly recommend paracentesis of the 

anterior chamber through the floor of the ulcer, the pupil having 

first been brought well under the influence of eserin to prevent 

prolapse of the iris. The good effect of this will be very soon 

apparent : the pain disappears, the patient sleeps, the ulcer becomes 

vascularized, and healing sets in. Cauterization of the ulcer in an 

early stage with the galvano-cautery is also good practice ; but in 
12 



138 DISEASES OF THE EYE. 

these cases I prefer the paracentesis. Many surgeons trust very 
much to eserin, warm fomentations, and a pressure bandage. 

For the fascicular keratitis the yellow oxid of mercury ointment 
is in its place. When the crescentic infiltration is very intense it 
is well to touch it with the galvano-cautery. Division of the leash 
of vessels at the margin of the cornea has a beneficial effect. 

For the ring ulcer a pressure bandage, under which an anti- 
septic dressing (boric or salicylic acid, or perchlorid of mercury) 
has been placed, is, perhaps, the best method of treatment. Warm 
fomentations promote vascular reaction, and may be used with 
benefit at each change of bandage. 

For primary phlyctenulse of the cornea, in the form of the 
minute gray superficial infiltration or ulcer, nothing beyond 
atropin, with warm fomentations, and a protective bandage to keep 
the eyelids quiet, should be used. When reparation of the ulcer 
has commenced, calomel or weak yellow oxid of mercury oint- 
ment may be employed. 

For the large purulent phlyctenula, resulting in a large and deep 
ulcer, often situated at the center of the cornea, with hypopyon and 
iritis, warm fomentations (camomile, or poppy-head, at 90° Fahr., 
for twenty minutes three times a day), atropin, boric acid as oint- 
ment or powder, and a protection bandage form the treatment in 
the early stages. Here, also, I often puncture the ulcer with the 
very best results in respect of hastening the cure, and the galvano- 
cautery may be used with advantage. In the stage of reparation 
the yellow oxid of mercury ointment or insufflations of calomel 
are very useful. 

In all forms of phylctenular ophthalmia those favorite remedies, 
blisters, setons, and leeching, should be avoided. The first two 
worry the patient, give rise to eczema of the skin, and are not to 
be compared in their power of cure with the measures above recom- 
mended; while leeching gives, at best, but temporary relief, and 
deprives the patient of blood which he much requires. 

For relief of the blepharospasm, in addition to the use of 
atropin, plunging the child's face into a basin of cold water is a 
most efficacious means. The face is kept under the water until 
the child struggles for breath, and this immersion is repeated two 
or three times in rapid succession, and used every day if neces- 
sary. It should always be used where the blepharospasm is severe, 
as the latter is not only distressing to the patient, but also an ob- 
stacle to the cure. 



PHLYCTENULAR OPHTHALMIA. 139 

The general treatment, notwithstanding the so-called photo- 
phobia, should consist in open-air exercise before everything else, 
unless, indeed, there be an ulcer which threatens to perforate. It 
is not well to keep the patient's face or eyes covered with bandages 
and shades, nor to confine him to a dark room. A pair of dark- 
blue glasses are the best protection from strong glare of light ; and 
shady places can be selected when the patient is out of doors. 
Cold or sea baths, followed by brisk dry rubbing. Easily assimi- 
lated food at regular meal hours, but no feeding between meals. 
Regulation of the bowels. Internally : cod-liver oil, maltine, iron, 
arsenic, syr. phosph. of lime, and such-like remedies are indicated. 

The great tendency to recurrence is one of the most troublesome 
peculiarities of all kinds of phlyctenular ophthalmia : and in order 
to prevent this, so far as possible, it is important to continue local 
treatment until the eye is perfectly white on the child's awaking 
in the morning, and even for fourteen days longer. This prolonga- 
tion of the treatment will also assist in clearing up opacities, as best 
they may be. For this after-course of treatment calomel insuffla- 
tions should be used. 

Nothing can be done for the opaque scars left on the cornea by 
ulcers when all inflammatory symptoms have subsided. If the 
ulcer have been very superficial the resulting scar in young chil- 
dren may disappear in the course of time. Deep ulcers cause more 
opaque and permanent scars, and ulcers which have perforated 
produce the greatest opacity. Some of the very disfiguring scars 
may be tattooed (see chap. vi.). 

The degree of the defect of vision to which an opacity of the 
cornea may give rise depends, in the first instance, on the position 
of the opacity. If it be peripheral, the vision may be perfect ; but 
if it be in the center of the cornea, sight may be seriously damaged. 
Even a slight nebula, barely visible to the observer, will cause 
serious disturbance of vision if situated in the center of the cornea ; 
while in the same situation the very opaque scar of a deep ulcer 
will produce a proportionately greater defect. If a central, but 
not deep, ulcer should not become completely filled up in healing, 
and a facet remain, vision will also suffer much in consequence of 
irregular refraction, although there may be but little opacity. 

Reference. 
^ " Klinische Monatsblatter fiir Augenheilkunde," 1869, p. 465. 



CHAPTER VI. 

DISEASES OF THE CORNEA. 

The importance of a knowledge of the diseases and injuries of 
the cornea depends on their great frequency, coupled with the fact 
that nearly every one of them is liable to leave behind it some 
opacity, with resulting defect of sight and disfigurement of the 
eye ; while several of them are very apt to lead to complete loss of 
sight. 

Inflammations of the Cornea. 

From a clinical standpoint these inflammations will be most con- 
veniently considered under the headings — (a) Ulcerative Inflam- 
mations and (b) Non-ulcerative Inflammations. 

(a) Ulcerative Inflammations of the Cornea. — Before an 
ulcer can form in the cornea there must be a cellular infiltration 
of its tissue near its anterior surface ; and this cellular infiltration 
is brought about, in most instances, if not in all, by the entrance 
into the cornea of certain micro-organisms^ the gonococcus, or the 
staphylococcus pyogenes, or other as yet undescribed forms. 
One recognizes the existence of an infiltration by seeing an opaque 
spot in the cornea, with a dullness of the layers over it, and often 
of the corresponding part of the epithelium. Before long the 
epithelium covering the infiltration comes away, and soon the in- 
tervening layers of the true cornea break down, and then we have 
an ulcer established. 

But although all ulcers of the cornea originate in an infiltra- 
tion, yet when once established they assume great varieties of type, 
in consequence, probably, of a variety in the nature of the origi- 
nating micrococcus. Some ulcers are purulent, others non- 
purulent; some tend to spread over the surface of the cornea, 
others tend to go deep into it ; some attack by preference the cen- 
tral region of the cornea, while others are confined to its margin; 
some readily give way to treatment, and others are very obstinate 
or almost incurable. Again, some ulcerative corneal processes are 
attended by much circumcorneal injection, severe pain in and 

140 



THE CORNEA. 141 

about the eye, great reflex blepharospasm, and lacrimation ; whilst 
others, which may really be more severe processes in so far as the 
integrity of the eye is concerned, can run their course with scarcely 
any injection of the eyeball, and with little or no distress to the 
patient. 

EtiologicaUy, corneal ulcers are primary or secondary. The 
primary ulcers are those in which the diseased process originates 
in the cornea, most commonly as the result of traumata, but also 
in phlyctenular keratitis, or as the result of corneal abscess, or 
where the nutrition of the cornea is interfered with, etc. Second- 
ary ulcers are those which are the result of disease elsewhere, 
usually in the conjunctiva, as in acute blennorrhea and in con- 
junctival diphtheritis. 

Corneal ulcers are more common in advanced than in early life. 
Indeed, in early life, unless in cases of blennorrhea neonatorum, 
and of phlyctenular disease, corneal ulcers are almost unknown. 
The greater liability to these affections in advanced life is due, no 
doubt, to a less active nutrition at that period in this already lowly 
organized part. Hence slight traumata, or the presence of a slight 
conjunctival catarrh, which would have no ill effect in a young 
person, may form the starting-point of a corneal ulcer in an old 
person or even in one of middle age. For the same reasons cor- 
neal ulcers are much more common in the lower orders than 
amongst the well-to-do; for the general nutrition of the poor is 
often defective, while they are more exposed to traumata than are 
the better classes. 

The Diagnosis of the presence of a large corneal ulcer is very 
simple. Inspection of the cornea in ordinary daylight at once re- 
veals the loss of substance, more or less extensive, deep, and in- 
filtrated. If the ulcer be very small and shallow the difficulty is 
greater, especially if there be much blepharospasm. In such cases 
the surgeon must endeavor to inspect the cornea from different 
points of view, either by directing the patient to move his eye, or 
by moving his own head, until he succeed in obtaining such an in- 
cidence of the light as will display the minute loss of substance, 
with its margin, and more or less gray infiltrated floor; or he may 
employ the focal illumination with artificial light. An instillation 
of cocain may be necessary to facilitate the examination by dimin- 
ishing the blepharospasm. 

It is obviously important to decide at the outset, for the pur- 
poses of prognosis and of treatment, whether a gray spot in the 



142 DISEASES OF THE EYE. 

cornea be an infiltration (a collection of cells which may shortly 
become an ulcer), an ulcer, or a scar (a healed ulcer, or other loss 
of substance). The surface covering an infiltration, although 
flush with the general surface of the cornea, has usually a steamy 
appearance, due to some disorganization of the corneal epithelium, 
and has no polish. With an ulcer the appearances already de- 
scribed will be found. The surface of a scar is usually, although 
not always, flush with the general surface of the cornea, and it 
has a polished surface — /. e., covered with normal epithelium, not 
rough, irregular, nor even steamy. In cases of corneal infiltration 
or ulceration there will be usually more or less pericorneal injec- 
tion, pain, and photophobia, while with a mere corneal scar there 
will be no irritability of the eye. 

A very beautiful method for ascertaining the presence and true 
extent of a corneal ulcer or traumatic loss of substance is the in- 
stillation of a 2 per cent, solution of fluorescin. Almost imme- 
diately after the instillation the tissue forming the floor of the loss 
of substance assume a greenish tint, which clearly differentiates 
it from the surrounding normal cornea. 

The presence of Hypopyon {vtto, under; ttvov, pus) is the 
rule with some types of corneal ulcer. Hypopyon is a deposit of 
pus in the anterior chamber, and as the patient sits or stands it lies 
in the lowest part of the chamber, to which place it has gravitated. 
If the patient lies in bed (say, on the side of the affected eye) the 
hypopyon will of course change its position, and gravitate towards 
the outer side of the chamber. Sometimes the hypopyon is so 
small as to be detected with difficulty ; and again it may fill the 
whole anterior chamber, completely obscuring the iris and render- 
ing a diagnosis of the condition of the cornea difficult. It will be 
asked. From w^hence does the pus come which forms hypopyon 
in cases of corneal ulcers? It might be supposed that it is de- 
rived directly from the purulent floor of the ulcer, by passage of 
the pus-cells through the posterior layers of the cornea. But this 
is not so. No pus-cells do, or indeed can, pass through the mem- 
brane of Descemet. Moreover, copious hypopyon is often present 
when the corneal ulcer is quite small and non-purulent. The pus- 
cells which form hypopyon in cases of corneal ulcer come from the 
iris, in compliance with the law which causes leukocytes to wan- 
der out of blood-vessels in the neighborhood of an inflammatory 
focus, and to make their way towards that focus. When these 
leukocytes from the iris reach the anterior chamber they can go 



THE CORXEA. 



H3 



no farther, owing to the barrier imposed to their progress by the 
membrane of Descemet. The pus forming a hypopyon is sterile. 
These interesting facts concerning the genesis and nature of hypo- 
pyon were discovered by Leber/^ whose observations have been 
corroborated by later observers. 

The Dangers attendant upon Corneal Ulcers are, first of all, the 




Fig. 52 — (Flicks). 

opacities, the scars, which even the slightest of them are apt to 
leave behind. 

Fig. 52 represents a section made through a deep ulcer in its 
progressive stage. At the margin of the ulcer the epithelium (e) 




53—(Fuchs). 



and Bowman's membrane (b) ceases. The floor of the ulcer is seen 
covered with pus, which also infiltrates the corneal tissue in the 
neighborhood. As soon as cure commences the floor of the ulcer 
begins to get clear — /. e., it becomes gradually less covered with 
pus — until it is finally quite free from it, and pari passu the sur- 



144 DISEASES OF THE EYE 

rounding infiltration is absorbed. Then the epithehum, growing 
in from the margin (m m, Fig. 53) all round, gradually carpets 
over the floor of the ulcer, and underneath this newly formed 
epithelium the new tissue, which is to close the loss of substance, 
'is laid down. This new tissue, however, is not corneal tissue, 
but is ordinary connective tissue, and is therefore opaque. Hence 
the deeper the ulcer, the more intense will be the resulting 
opacity. Bowman's membrane never becomes restored over the 
^cicatrix. 

The ulcers which are situated at the center of the cornea, in 
the pupillary area, are more serious for sight than those situ- 
ated peripherally, as can be readily understood. The opacity left 
by a very superficial ulcer is slight, and is called a nebula; a 
somewhat more intense opacity is called a macula ; and a very 
marked white scar is called a leukoma. 

But a more serious danger connected with ulcers of the cornea 
than the opacities they leave behind is that of perforation of the 
cornea, to which some ulcers are very prone. For an account of 
the consequences of perforation see pp. 103, 147, and 171. 

In the Treatment of primary corneal ulcers the student will 
soon perceive that a bandage, atropin, and warm fomentations 
play prominent parts; and these measures alone are sufficient to 
produce cure in the less severe cases. 

The bandage should be put on with firm pressure, — but should 
not be made uncomfortably tight, — the eye having been pre- 
viously padded out, especially at the inner canthus, so that equal 
pressure may be exercised on the globe all over. The support 
thus given to the cornea and front of the eye promotes the heal- 
ing process in the ulcer, and the bandage is also useful by pre- 
.venting the eyelids from rubbing over the ulcer, and by keeping 
small foreign bodies from it. In secondary ulcers, due to severe 
conjunctival processes, such as blennorhea, a bandage is contra- 
indicated, because it retains the secretion, and therefore would 
do more harm than good. 

Atropin in sufficient quantities to keep the pupil dilated should 
be employed. Iritis very often attends severe corneal ulcers, and 
here the indication for atropin is obvious. But rest of the 
.affected part is, we know, an important element in preventing or 
in curing any inflammation; and in the affections we are now 
treating of, even where there is no iritis, atropin acts by procuring 
rest of the iris and of the ciliary muscle, the constant motion of 



THE CORNEA. 145 

which would otherwise tend to augment the inflammatory process 
in the cornea. 

Some surgeons use myotics (eserin, or pilocarpin) in prefer- 
ence to atropin in the treatment of corneal ulcers. They hold that 
their power of reducing the intra-ocular tension encourages heal- 
ing of the ulcers ; while they also think the more extended surface 
of iris presented facilitates absorption of the hypopyon. But it 
is doubtful whether myotics do reduce the normal tension, al- 
though they often have that effect upon abnormal tension ; and 
my objection to them in these cases is that they increase, I believe, 
the tendency to iritis. Absorption of the hypopyon will only 
come about when the cornea begins to recover, whatever the 
treatment may be. I am not singular in this view of the use of 
eserin in corneal ulcers ; yet a clear indication for myotics is 
given by the presence of an ulcer near the corneal margin which 
has a tendency to perforate, for here the myosis would assist in 
preventing prolapse of the iris, should perforation take place. 

Warm fomentations promote the healing process by stimulat- 
ing tissue-changes in the cornea. One usually orders them to be 
made with poppy-head water or camomile tea, although no doubt 
warm water would be equally efficacious. Hot solutions of 4 
per cent, boric acid, or i in 5000 corrosive sublimate, may be 
used with advantage. The bandage having been removed, a 
compress of lint dipped in the stupe at about 120° Fahr. is laid 
upon the eye, and frequently replaced by fresh compresses out of 
the stupe, so that the one on the eye may be always hot. This is 
continued for half an hour at a time, and repeated every two or 
three hours. Or, the Japanese mufif-w^armer may be applied. 

In an ulcer of a purulent or sloughing nature the insufflation 
on its floor of very finely divided xeroform powder is useful. 

When more active measures than the foregoing are called for, 
the actual cautery, scraping, and paracentesis have to be re- 
lied on. 

The actual cautery has of late years come much into use in the 
treatment of serpiginous and other purulent corneal ulcers. It 
acts by destroying the micro-organisms, which keep the process 
going. Either a thermo-cautere, in the form of a very fine point, 
or the galvano-cautery (Fig. 54), may be employed, and per- 
sonally I prefer to work with the former. To the galvano- 
cautery a medium-sized bichromate of potash bottle-battery is at- 
tached, and the platinum wire brought to a red-heat. The eye 



46 



DISEASES OF THE EYE. 



having been cocainized, the red-hot cautery is brought into con- 
tact with the whole surface of the ulcer, so as to thoroughly de= 





Fig. 54. — The bolt A being pushed forwards, the current is completed, and 
passes through the platinum wire which forms the cautery. By 
pressure on the button B the current can be momentarily intercepted 
during use of the instrument. 



THE CORNEA. 147 

stroy its superficial layer, and special attention is paid to any part 
of the margin of the ulcer where it seems inclined to spread to as 
yet healthy tissue. Fluorescin may be used to show the extent 
of the ulcerated surface. The cauterization can be repeated as 
often as the progress of the ulcer makes it desirable. It is well 
to perforate the cornea with the cautery, and to evacuate the 
aqueous humor and hypopyon ; or this may be done with an 
ordinary paracentesis needle, after the cauterization is completed. 
My own experience of the cautery in these cases is extremely 
satisfactory. It seems to give the best percentage of cures with 
the least amount of opacity. 

Thorough scraping of the floor of the ulcer with a small sharp 
spoon is a valuable method. 

Paracentesis of the anterior chamber through the floor of the 
ulcer is another most valuable therapeutic measure for some cor- 
neal ulcers, and deserves a more routine application in these cases 
than is at present accorded to it ; the more so as the little opera- 
tion is simple and dangerless. But here are, I think, two impera- 



FiG. 55. 

tive indications for its use, namely: (i) If there be great pain. 
Very shortly after the operation, which for the moment increases 
the neuralgia, the patient experiences the greatest relief, and 
passes the first good night after many wakeful ones. (2) If per- 
foration seem to be imminent. This may often be recognized by 
a bulging forwards of the thin floor of the ulcer; but sometimes 
it is not easily foreseen, and if there be any doubt on the point, 
paracentesis should be performed. It is important to forestall 
spontaneous perforation of the ulcer by this proceeding, because 
the opening made by the latter being linear it heals easily, and 
leaves but a slight scar without anterior synechia ; while the 
natural opening would be a complete loss of substance, and, there- 
fore, the more readily involve adhesion of the iris in the result- 
ing comparatively extensive cicatrix. Other indications for the 
operation are increased tension and the presence of a large 
hypopyon. 

Paracentesis of the anterior chamber is best performed by 
means of a paracentesis needle (Fig. 55), which is a somewhat 



148 DISEASES OF THE EYE. 

shovel-shaped instrument, with a shoulder or stop. If this be 
not at hand, a small keratome, or broad needle, or a Graefe's 
cataract knife with answer the purpose. The eye having been 
cocainized, a spring lid-speculum is inserted, the eye fixed with a 
fixation forceps, and the point of the paracentesis needle applied 
to the floor of the ulcer, in such a way that the plane of the little 
blade may be at an angle of about 45° with that of the floor 
of the ulcer. The point is pushed gently through the floor, 
and the plane of the blade is then immediately changed, so that, 
as the instrument is being advanced up to the shoulder, it may 
be almost in contact with the posterior surface of the cornea. The 
instrument should be withdrawn very slowly, in order that the 
aqueous humor may flow ofif gradually, and not with a rush. If 
these precautions be taken, there need be no danger of injuring 
the crystalline lens, or of having prolapse of the iris in the in- 
cision. If the latter should occur, it can usually be reposed with 
the spatula. It may happen that when the needle has been quite 
withdrawn a considerable portion of the aqueous humor may 
still remain in the anterior chamber, unable to escape owing to 
the valve-like closure of the wound. It should be evacuated by 
making the wound gape by gentle pressure with a spatula on its 
posterior lip. If it be desirable to tap the anterior chamber on 
the next day, it can be done by simply opening up the wound with 
a cpatula, or with the probe-like instrument at the other end of 
the handle (Fig. 55), without the aid of any cutting instrument. 
If the case does not come under the care of the surgeon until 
perforation of the ulcer, with prolapse of the iris, has taken 
place, the very important question as to the best method of 
dealing with the condition is presented. The same question 
arises in other forms of perforating ulcer. If the loss of sub- 
stance occupies one-third or more of the cornea, with correspond- 
ingly large prolapse oi iris, little can be done beyond the use of 
eserin — and here I would use eserin — to reduce the intra- 
ocular pressure, along with the application of a firm bandage ; for 
in such cases the formation of a corneal staphyloma is almost in- 
evitable. But if the ulcer and prolapse be small, an attempt may 
be made to free the iris, so that no anterior synechia may form, 
and in order that the cicatrix may be flat, and not raised over the 
surface of the cornea, and, consequently, exposed to injury. The 
importance of such an attempt lies in the fact that a corneal cica- 
trix with iris entangled in it — not merely adherent to its posterior 



THE CORNEA. 149 

surface — affords a constant source of danger, especially if situated 
near the margin of the cornea ; for in such eyes sudden and un- 
controllable purulent inflammation of the iris and chorioid may 
come on after an apparently slight trauma, and end in total de- 
struction of the eye. This event is due to septic infection reach- 
ing the interior of the eye through a superficial loss of sub- 
stance, the direct result of the trauma. The surgeon's attention 
should, therefore, be directed to obtain at least as flat a cicatrix 
as possible, or, still better, a non-adherent cicatrix. The prac- 
tice which I, as well as many other surgeons, have commonly 
followed, is to draw the prolapsed portion of iris lightly forwards 
with a forceps, and to snip it off level with the surface of the 
cornea; and then with a spatula to endeavor to free the iris from 
any adhesions it may have formed with the margin of the ulcer. 
Atropin or eserin, according to the position of the ulcer, is then 
instilled, and a bandage carefully applied. This proceeding is 
only of use when a fresh prolapse can be dealt with, before cica- 
trization sets in ; and the result is often satisfactory in so far 
as the securing of a flat cicatrix is concerned, but an anterior 
synechia can rarely be avoided. 

Da Gama Pinto has successfully employed the following 
method for obtaining a non-adherent cicatrix: — Having abscised 
the prolapsed portion of iris as above, and freed all adhesions 
to the margin of the ulcer with a spatula, he covers the opening 
in the cornea with a flap cut from the bulbar conjunctiva, — and 
this flap should be twice as large as the opening, in order to ad- 
mit of its shrinkage, — and then pushes the flap into the opening 
with a blunt probe. A firm binocular bandage is applied — but no 
iodoform. The eye is not dressed until the third day, when the 
anterior chamber is often found restored, the iris all in its proper 
plane, and the conjunctival flap healed into the ulcer. Ultimately 
all trace of the flap disappears, and an ordinary non-adherent 
corneal scar is presented. I have employed this method, and in 
each case with a good result. Kuhnt also uses it, and he recom- 
mends, too,^ a covering of the ulcer by means of a conjunctival 
flap of which a pedicle is retained, and which is drawn over the 
ulcer. 

From time to time different types of corneal ulcers have been 
recognized and described. The following are the chief of them : 

Simple Ulcer. — This may result from a slight trauma, or 
from the bursting of a phlyctenula. It presents the appearance 



ISO DISEASES OF THE EYE. 

of a minute and shallow depression with a gray floor on the 
surface of the cornea. There is circumcorneal vascularity, espe- 
cially at that part of the corneal margin nearest to which the ulcer 
is situated ; the pupil is apt to be contracted, although iritis is 
not present, and there is often a good deal of pain, lacrimation, 
and photophobia. 

Treatment and Prognosis. — The eye is to be bandaged, warm 
fomentations applied several times a day, and a drop of solution 
of atropin instilled night and morning. When of 'phlyctenular 
origin, stimulation with the yellow oxid ointment is indicated. 
Cure, with slight opacity remaining, comes about in a week or ten 
days. But occasionally this form of ulcer may pass over to the 
deep ulcer. 

Deep Ulcer. — This is a purulent ulcer, and commences in a 
purulent infiltration of the cornea. It forms a tolerably deep 
pit in the cornea towards its center, the floor of the ulcer being 
covered with purulent deposit and detritus, and the corneal tissue 
immediately surrounding it being somewhat infiltrated with pus. 
The ulcer is generally round, but it may assume any shape. Hy- 
popyon is often present, and a marked tendency to iritis exists. 
The pain is usually very severe, violent frontal neuralgia being a 
common symptom. 

This ulcer has no great tendency to spread over the surface 
of the cornea, but has a very decided tendency to perforate 
through it. As it does not generally attain wide dimensions, the 
perforation it may produce is small, and gives rise to a small ad- 
herent leukoma rather than to a staphyloma. This ulcer seldom 
causes complete loss of the eye. 

Causes. — This form of ulcer is a frequent one in purulent con- 
junctivitis, and it may be caused by the lodgment of foreign 
bodies, and other injuries of the cornea. 

Treatment. — If the ulcer be due to a conjunctival process, the 
latter should be actively treated. 

If the cause be other than conjunctival, a pressure bandage to 
give support to the ulcer is important, and periodical warm fo- 
mentations are most beneficial. Where the cause is conjunctival 
(purulent conjunctivitis), neither a bandage nor warm fomenta- 
tions can be used. Atropin should be instilled several times 
daily. Antiseptic applications, especially xeroform, are useful. 

Paracentesis of the anterior chamber through the floor of the 
ulcer is a proceeding always followed by improvement in the 



THE CORNEA. 151 

condition of the eye, and is very important as a preventive of 
natural perforation. The actual cautery, too, is in its place 
here. 

Serpiginous Ulcer (Ulcus Serpens, Saemisch's Ulcer). This 
also is a purulent ulcer, the characteristic of which is its tend- 
ency to creep over the surface of the cornea, especially in some 
one direction, rather than to strike deep into its tissue. Its posi- 
tion is chiefly central, and it presents a grayish floor, which is 
more intensely opaque at some places. One part of the margin 
takes the form of a curve, or of several closely placed curves, 
and at this place the margin becomes yellowish-white in color and 
somewhat raised, and the floor of the ulcer seems deeper in its 
neighborhood. Immediately around the ulcer the cornea is slightly 
opaque, but farther out it is normal. 

The degree of pain and irritation varies much, being almost 
absent in some cases, while in others it is extremely intense. 
Iritis is apt to come on at an early period, and may pass into 
irido-cyclitis. Hypopyon is almost always present, and on the 
posterior surface of the cornea, from the region corresponding 
to the ulcer on the anterior surface, a line of pus is sometimes seen 
extending down to the hypopyon, and this was formerly taken as 
a proof that the hypopyon was formed by direct transmission of 
the pus-corpuscles through the cornea from the ulcer. The ulcer 
creeps over the surface of the cornea in the direction of the 
curved and intensely infiltrated margin. At a still later stage 
the whole cornea is apt to become infiltrated, and the entire 
margin of the ulcer to extend, and the anterior chamber becomes 
quite full of pus. Perforation now takes place, or may do so 
somewhat earlier. If the perforation be small, an adherent leu- 
koma results ; but if large, a staphyloma is gradually produced, 
or panophthalmitis may immediately follow on the perforation. 

Causes. — Ulcus Serpens always has its origin in a trauma, 
which has produced, it may be, only a slight abrasion of the epi- 
thelium. In perhaps 50 per cent, of the cases chronic dacryo- 
cystitis is present, and in about 25 per cent, more there is ozena, 
and a considerable proportion of them occur in the warm summer 
months ; and the agricultural population, especially during har- 
vest-time, when injuries to the cornea are frequent, are very liable 
to it. The specific excitant of this ulcer is the pneumococcus, 
which can be found in its spreading margins, and which may 
also be found in the secretion from the diseased lacrimal sac. 



152 DISEASES OF THE EYE. 

Prognosis. — From the above description it will be seen that 
the process is a very severe one in many instances, and the 
prognosis unfavorable; yet some cases do recover useful, al- 
though damaged, sight under careful treatment, if it has been 
resorted to in time. 

Treatment. — If the case be not severe, atropin, with protection 
of the eye, may cure in a few days. Here, too, some surgeons 
prescribe eserin, but I am opposed to its use. Warm fomenta- 
tions should not be used, as they rather promote the activity of 
the diseased process; and the eye should not be bandaged, lest 
infective discharge be retained in the conjunctival sac. Anti- 
septic measures should always be employed, xeroform being the 
application most likely to prove of use. It may be employed 
either in the form of a strong ointment (gr. xxx ad §j) put into 
the eye, or it may be insufflated on the floor of the ulcer with a 
powder-blower. The floor of the ulcer may be washed with 
tincture of iodin, a solution of sublimate i in 5000, or other anti- 
septic solutions which do not act as caustics, the action of which 
on the healthy surrounding tissues might be difficult to control. 
Scraping the floor of the ulcer with a sharp spoon is a useful 
procedure. But it is in all respects wiser to deal with these 
cases, even the apparently mild ones, actively in the very com- 
mencement by means of one or other, preferably the second, of the 
two following methods. 

Saemisch's Method consists in division of the ulcer with a 
Graefe's cataract knofe. Cocain having been applied, the point 
of the instrument is entered about 2 mm. from the margin of the 
ulcer in the healthy corneal tissue, and, having been passed 
through the anterior chamber behind the ulcer, the counter- 
puncture is made in the healthy cornea some 2 mm. from the 
opposite margin of the ulcer. The edge of the knife being then 
turned forwards, the section is slowly completed. The incision 
should divide the intensely infiltrated part of the margin in 
halves. The aqueous humor and hypopyon are evacuated, atropin 
is instilled, a bandage is applied, and the patient soon gets relief 
from pain. Every day, until healing of the ulcer is well estab- 
lished, the wound must be opened up from end to end with the 
point of a fine probe or spatula, the contents of the anterior 
chamber being thoroughly evacuated on each occasion, and atropin 
instilled. The result is that, in a vast majority of cases, the 
progress of the ulcer is arrested, and healing soon sets in. The 



THE CORNEA. 153 

little operation should not be delayed long, but it may be em- 
ployed with advantage even in late stages of the process. 

But the Actual Cautery is the most valuable method of treat- 
ment for this ulcer. The infiltrated and undermined margin 
of the ulcer is the part which should be most thoroughly cauter- 
ized; but its floor, if much infiltrated, is also to be dealt with. 
The application of fluorescin just before the use of the cautery 
is of much value, as it enables the operator to clearly discern the 
whole of the diseased part requiring cauterization. 

At the thinnest part of the floor of an extensive serpiginous 
ulcer it is desirable to make a perforation through the cornea 
with the point of the cautery ; or, instead of this, when the 
cauterization is finished, the cornea may be paracentesed with a 
broad needle in a sound region beyond the ulcer. The object 
is to reduce the intra-ocular tension, and thus promote the nutri- 
tion of the cornea. 

Subconjunctival injections of a four per cent, saline solution 
are found to assist the cure, although the explanation of this is 
not at present apparent. 

Where there is dacryocystitis it is of the utmost importance 
at least to modify its virulence by treatment (vide chap, viii.) ; 
or, much better, to effect the radical cure by extirpation of the 
lacrimal sac. These ulcers require prompt relief before the time 
is passed when relief can be of any practical use ; and the cautery 
undoubtedly affords the best prospect of aid of that kind. Even 
the cautery is too often ineffectual to arrest the progress of the 
ulceration. 

Rodent Ulcer. — This is a rare and extremely dangerous form 
of ulcer, which was described by Mooren,^ and it must not be 
confounded with the serpiginous ulcer. It is not a purulent 
ulcer. It appears as a small — sometimes even pinhead-sized — 
gray infiltration near the corneal margin, not differing in appear- 
ance from many a harmless catarrhal infiltration. This rapidly 
ulcerates. Other similar infiltrations appear in the neighbor- 
hood and at other parts of the margin, and ulcerate, and the 
ulcers coalesce into one, of which the margin nearest the center 
of the cornea is undermined. There is very great pain in some 
cases, and in others hardly any. The eyeball is injected. The 
ulcer does not go deeper than about one-fourth of the thickness 
of the cornea, and perforation seldom occurs. Occasionally a 
very small hvpopyon is present. Before long the ulcer begins to 
'3 



154 DISEASES OF THE EYE. 

be vascularized and to heal, and finally leaves an intense cicatrix 
behind. Gradually the ulceration creeps round the cornea, and at 
the same time advances towards its center, healing going on the 
while in the oldest portions of the ulcer. This process goes on 
until, finally, the whole surface of the cornea has been eaten 
away, and cicatricial tissue substituted for it, its center being the 
last place affected, and then vision will have become reduced 
to finger-counting or to perception of light. Clearing up of the 
corneal opacity to a certain extent may subsequently take place, 
but cannot be reckoned upon. Yet in a few cases fairly good 
vision has been regained. The disease usually comes on in both 
eyes, although there may be an interval between the onset in each, 
of weeks, or months, or more. It attacks decrepit people of 
over middle life, but it also occurs in young persons and in those 
of apparently robust health. Its etiology is obscure. No spe- 
cific micro-organism has as yet been discovered as the immediate 
cause. The progress of the disease is very slow, many weeks or 
even some months often elapsing before the surface of the whole 
cornea has been destroyed. 

The onset at the edge of the cornea in the form of small gray 
infiltrations, the gray and shallow floor of the ulcer, its pale gray 
or almost white margin, the undermining of this margin (which 
may readily be ascertained by passing the point of a probe under 
it), and the steady advance of the ulceration towards the center 
and around the edge of the cornea, are the characteristics of this 
disease. 

Treatment. — The general nutrition of the individual is to be 
improved, but reliance is mainly to be placed on local treat- 
ment, which should especially be directed to the undermined 
margin. The actual cautery may save the eye in some few cases. 
Scraping, tincture of iodin applied with a camel's-hair pencil, 
sublimate lotion, carbolic acid, with a bandage and the usual 
warm fomentations, may help in the treatment. The covering 
of the diseased part — after it has been well cauterized — or of 
the entire cornea, with a conjunctival flap, is a measure which is 
well worth the trial. Quite recently I observed in one case — 
the only case in which I have as yet tried it — that the applica- 
tion of absolute alcohol to the ulcer arrested its progress. 

Prognosis. — From what has been said, it is evident that the 
prognosis in these cases is very unfavorable. 

Marginal Ring Ulcer is a rare form, which commences as 



THE CORNEA. 155 

a clean-cut, or but slightly infiltrated, yet rather deep, ulcer at 
the corneal margin. Its tendency is to extend along the margin 
of the cornea; and in some instances healing takes place in the 
older parts of the ulcer while it is still progressive at the newer 
parts. It may extend all round the cornea, and finally give rise 
to complete sloughing of the latter by cutting off its nutrition. 
This ulcer may result in children from a marginal phlyctenular 
infiltration (p. 134), but is more common in adults, or in aged 
people whose nutrition has fallen very low. 

Treatment.: — The actual cautery. Paracentesis through the 
ulcer, eserin having been first instilled. Insufflation of xeroform. 
Warm fomentations. A bandage. Quinin, iron, and strychnin 
internally, with nutritious diet. 

Absorption Ulcer (Faceted Ulcer, Superficial Transparent 
Ulcer) is the term applied to a certain definite superficial ulcera- 
tion which is accompanied by but little opacity and by no vascu- 
larization, and which is usually seated at or near the center of 
the cornea, where it presents the appearance of a shallow pit 
about 2 mm. broad, with rounded margin, its floor being cov- 
ered with epithelium. If the eye be exposed to cold, wind, or 
other irritation, some circumcorneal injection makes its appear- 
ance, and there is lacrimation ; but these symptoms soon pass off 
again. The healing process may take months to be completed, 
and slight opacity remains. Often the defect is never quite filled 
up, but a small facet is left, which is liable to interfere with 
vision. 

The absorption ulcer does not tend to perforate, nor to spread 
over the surface of the cornea. 

It occurs chiefly in childhood, and probably indicates malnu- 
trition of the general system ; some observers, indeed, think there 
is a close relationship between it and phlyctenular ophthalmia. 
It is also seen in granular ophthalmia, with and without pannus. 

Treatment consists in atropin and protection, with a bandage 
in the early stages ; and the yellow oxid ointment in the later 
stages. General treatment with suitable tonics is indicated. 

Neuro-Paralytic Keratitis. — In paralysis of the Ophthalmic 
Division of the Fifth Nerve purulent infiltration with hypopyon 
and ulceration of the cornea is often observed. It was formerly 
believed that the fifth nerve had an influence over the nutrition of 
the cornea, and hence that this was a trophic process ; but experi- 
ment has shown that this is not the case, and that the affection 



156 DISEASES OF THE EYE. 

is merely due to the loss of sensation, and consequent drying and 
disorganization of the epithelium, which renders it possible for 
septic infection of the cornea to take place. This disease, there- 
fore, cannot be regarded as of neuropathic origin in the strict 
sense of the term. 

Treatment consists chiefly in protection of the cornea by a 
bandage on the eye, or by keeping the lids fastened together with 
a dermic suture. 

Infantile Ulceration of the Cornea, with Xerosis of the Con- 
junctiva, first described by von Graefe,-" is a very rare affection. 
It attacks some marasmatic children early in the first year of 
life, making its appearance at or near the center of the 
cornea. Iritis always supervenes in severe cases. That portion 
of the bulbar conjunctiva which is exposed in the palpebral aper- 
ture at either side of the cornea undergoes slight epithelial xerosis, 
as in functional night blindness, due to retinal exhaustion (see 
chap. xvii.). Sometimes the xerosis of the conjunctiva is ab- 
sent,* as Holmes Spicer has shown. Ulceration of the cornea 
soon comes on, through necrosis of the layers lying over an inter- 
stitial infiltration ; and this ulceration spreads until it involves 
the whole of the cornea, except a very narrow margin. Finally, 
perforation, with prolapse of the iris, and panophthalmitis may 
supervene. 

Both eyes become afifected as a rule, although the disease 
usually attacks one eye some time before its fellow. The pa- 
tients almost always die of diarrhea, pneumonia, etc. 

Cause. — Streptococci have been found ^ in the corneal ulcer 
and in the conjunctiva, while a general invasion of the vascular 
system of the whole body is also present. To the latter circum- 
stance are referred the symptoms which lead to a fatal termina- 
tion. 

Treatment is, unfortunately, of very little avail; but warm 
fomentations and the use of non-irritating antiseptic lotions, etc., 
are indicated, along with an antiseptic bandage. Such means as 
may possibly promote improvement of the general system are 
obviously called for. 

Herpes Corneae Febrilis. — Not only in herpes zoster ophthal- 
micus, but also in herpes febrilis (or catarrhalis) is a vesicular 
eruption liable to occur on the cornea. According to the late 
Professor Horner, herpes corne?e febrilis is a rather common 
affection, and, he believed, is often not recognized by ophthal- 



THE CORNEA. 157 

mologists because it usually first comes under their notice when 
the secondary ulcers have formed. The following is Horner's 
description of the disease: 

On the surface of the cornea of one eye is formed a group of 
clear vesicles, each from 0.5 to i.o mm. in diameter, their appear- 
ance being accompanied by much lacrimation, but without any 
swelling of the eyelid. They usually form in a line, which runs 
obliquely across the cornea, or sometimes in a vertical direction. 
Now and then they are arranged in trefoil shape or in a circle. 
The covering of the vesicles is short-lived, and, as already re- 
marked, the resulting ulcer is that which the surgeon usually first 
sees. Even it, however, is thoroughly characteristic. On the 
surface of the clear cornea is an irregular loss of epithelium, 
along the margins of which may still sometimes be seen the shreds 
of the late covering of the vesicle. The margin of the region 
which is bared of its epithelium is dentated, and can only be mis- 
taken for a traumatic loss of epithelium. The latter, however, 
would never present the peculiar " string-of-beads " appearance. 
The floor of the loss of substance is formed by the superficial 
layers of the cornea, and the anesthesia of the cornea is confined 
to this place, and does not, as in herpes zoster, extend to the rest 
of the cornea. The tension of the eye is generally reduced. Un- 
der favorable circumstances this loss of epithelium may be rapidly 
repaired ; although even then more slowly than one of equal di- 
mensions, but of traumatic origin. Usually the healing process 
is slow ; and sometimes more or less intense opacities form in the 
area and at the margin of the ulcer, with hypopyon, iritis, etc., 
and the loss of substance becomes deep, with a dentated margin. 
This more unfavorable course is the result of secondary infection 
of the ulcer. 

The subjective sensations are those of a foreign body in the 
eye, with lacrimation and photophobia, and are relieved imme- 
diately after the bursting of the vesicles. 

The vesicular eruption is often regarded as irritation from a 
foreign body merely ; or, occurring in the course of a serious 
disease (pneumonia, typhoid fever, intermittent fever, etc.), it 
passes wholly unnoticed, and its relationship to the latter re- 
mains unrecognized. 

The only affection for which herpes corneae is likely to be mis- 
taken is phlyctenular keratitis ; but the clear elevated vesicles will 
readily be distinguished from the flatter grayish mass of cells 



158 DISEASES OF THE EYE, 

which form the phlyctene. In herpes there is never — although 
often in phlyctenular keratitis — a vascularization of the cornea. 
The shape of the loss of epithelium after bursting" of a herpes 
vesicle is characteristic. Phlyctenular keratitis is a disease of 
childhood, while herpes corneie is rare under puberty. 

The derangements of the system in which herpes corneae fe- 
brilis occurs are naturally those in which herpes febrilis labii, 
nasi, etc., are found. These are more especially the inflam- 
matory affections of the respiratory tract, from an acute catarrh 
of the Schneiderian mucous membrane to a severe pneumonia. 
On two occasions, with an interval of three years, Professor 
Horner saw herpes cornese occur in the course of an attack of 
pneumonia in a boy. In just such cases herpes on the lips, ala 
nasi, external ear and eyelid of the same side are found ; and in 
a case of double pneumonia in an adult occurred the only bin- 
ocular herpes corneae which Professor Horner had seen. He 
explicitly states that he had seen herpes corneae in connection 
with whooping-cough, and often with intermittent and typhoid 
fevers. 

But primary herpes corneae — L e,, unconnected with any other 
disease — is occasionally met with ; and some patients are liable 
to recurrent attacks of it. It is accompanied by severe neuralgia 
in the frontal and temporal regions, and pain on pressure of the 
supraorbital notch may be present. There is much lacrimation. 
The upper lid is red and swollen. The bulbar conjunctiva, espe- 
cially around the cornea, is much infected, and there may be a 
few vesicles on it. Over the surface of the cornea, but some- 
times confined to some one district of it, there are a number of 
minute vesicles, some shreds of epidermis — the remains of rup- 
tured vesicles — and round grayish-white superficial infiltrations 
not larger than a pin's head. The mucous membrane of the 
nostrils is also apt to be attacked, causing swelling of it, with much 
secretion, and the formation of scabs. 

Treatment at an early stage, before the vesicles have burst 
or the loss of substance has become infiltrated, consists in pro- 
tection of the eye, and, when infiltration has set in, in disinfection, 
with protection. If the vesicles give great pain they may be rup- 
tured by dusting a little calomel into the eye, or by brushing it with 
a camel's-hair pencil wet with solution of boric acid, after which 
a well-fitting antiseptic bandage is applied. Cocain is valuable 
in these cases for relief of the pain. Atropin and warm fomenta- 



THE CORNEA. 159 

tions should also be employedj and a weak yellow oxid ointment 
is of use in some cases. Where the nostrils are affected weak 
sublmiate or other antiseptic washes should be applied to the 
Schneiderian mucous membrane. 

Filamentary Keratitis (Fadchen-Keratitis). — This is very 
rare. It may occur with or without superficial injury to the 
cornea. Its name is due to the fine threads, like twisted spun- 
glass, several of which hang from the surface of the cornea, and 
give the condition its characteristic appearance. These threads 
never reach a length of more than 3 or 4 mm. 

Different views are held as to the mode of origin of the 
threads. Fischer and Uhthoff ^ have observed that small ves- 
icles, with clear or turbid contents, appear in groups upon part 
of the cornea, then burst, and from the center of each resulting 
depression a thread hangs out. The onset of the vesicles is ac- 
companied by much pain and photophobia, and probably has its 
cause in some affection of the fifth nerve. The duration of an 
attack is usually short, but there may be sevral relapses at brief 
intervals, and finally the process ceases without permanent dam- 
age to the cornea. These same authors hold that the threads are 
composed of the peculiar fibrinous contents of the vesicles. But 
it has now been proved beyond doubt by the investigations of 
Hess ' and Nuel ^ that the threads are composed of twisted pro- 
liferating epithelial cells, each thread ending in a bulbous enlarge- 
ment caused by degeneration of the epithelium. A peculiar dis- 
eased condition of the corneal epithelium precedes the formation 
of the vesicles and threads. 

Treatment. — The instillation of a 3 per cent, solution of chlo- 
rid of ammonium into the eye every two hours, by which the 
exfoliation of the epithelial growth is promoted and hastened. 
Protection of the eye with a bandage is important. 

Bullous Keratitis. — Bullae very rarely form on the cornea. 
They are seldom the primary condition, but usually depend on 
an interstitial diseased process in the cornea. This process may 
itself be a primary disease ; but more commonly it, too, is sec- 
ondary to deep changes in the eye, such as absolute glaucoma, 
irido-cyclitis,etc. I have a few times seen bullae form on the cornea 
of otherwise sound eyes in persons whose health was in a de- 
bilitated state. The formation of a bulla is attended by much pain 
and photophobia, which disappear as soon as the bulla ruptures. 
One, or more than one, bulla may form at a time. After a day 



i6o DISEASES OF THE EYE. 

or two they rupture, and their walls then hang in shreds from 
the surface of the cornea, and the seats of the bullae present shal- 
low depressions. These losses of substance heal without leav- 
ing any permanent opacity. After an interval of days or weeks 
another crop of bullae appears, and runs the same course. 

Treatment. — The bullae should be opened, and their walls 
snipped away with a scissors, and a bandage applied. The recur- 
rent attacks may cease after a length of time ; but so far as treat- 
ment can influence them it can only be done by relieving the 
process in the cornea which gives rise to them. If it be a primary 
process warm fomentations, atropin, and a bandage, with rem- 
edies directed to correction of any fault in the general state of the 
health which may exist, are suitable; or if, as is more common, 
a deep ocular process (glaucoma, etc.) be the cause, the recog- 
nized treatment for this latter must be adopted. 

Dendriform (divdpov^a tree) Keratitis. — This is a rare affec- 
tion, to which attention was first drawn by Hansen Grut, of 
Copenhagen. It is a very superficial and chronic ulceration, with 
but little infiltration of its margins or floor, and presents the ap- 
pearance of a fine groove on the cornea. It spreads chiefly over 
the central region of the cornea by throwing out branches on 
either side. The pain and irritation are sometimes severe, and 
again but slight or quite wanting. Some slight permanent opac- 
ity may remain when cure has been effected. 

The Cause has not been definitely ascertained, but the peculiar 
progress of the affection renders it almost certain that some 
special fungus is engaged. 

It must, however, be stated that the opinion is strongly held by 
some that these ulcers result from a herpetic eruption on the 
cornea — in short, that they are the ulcers observed by Horner as 
the result of herpes corneae febrilis (p. 156). 

Treatment. — Scraping with a sharp spoon, with the subse- 
quent application of i in 1000 solution of corrosive sublimate to 
the cornea, is recommended by some, also the application of pure 
carbolic acid to the ulcer with a fine camel's-hair pencil, care 
being taken to confine it to the ulcer, and the actual cautery is 
sometimes useful. 

I can strongly recommend the application of absolute alcohol. 
A small bit of lint is folded to a point, and the latter is dipped 
in the alcohol. The ulcerated portion of the cornea is then 
rubbed with the point with such pressure as to take away the 



THE CORNEA. i6i 

epithelium, and, so far as possible, the rest of the cornea is 
avoided. Immediately afterwards the conjunctival sac is freely 
washed out with sterilized salt solution, to remove all surplus al- 
cohol which would increase the subsequent pain. Usually one 
application is sufficient to produce cure, but some cases require 
it to be repeated after four or five days. 

I have also found the application of a fine point of sulphate of 
copper to the ulceration produces good cures. It is less painful 
than the alcohol, because its action is easily confined to the ulcer- 
ated part. 

Keratitis Aspergillina. — This disease was described by Le- 
ber,^ and some seven or eight cases of it have been published. The 
appearance presented is that of an ulcer from 3 to 5 mm. in di- 
ameter, occupying a rather central position in the cornea. The 
surface or floor of the ulcer is of a pale grayish yellow, and is 
very irregular. A striking and characteristic appearance is the 
dryness of this surface, the copious discharge of tears flowing 
over it without seeming to wet it. The rest of the cornea is 
slightly opaque and dull, and there is a small hypopyon present. 
The conjunctiva is injected and swollen, and is covered with some 
mucous secretion. The eyelids are rather swollen. There is pho- 
tophobia and often severe pain. Masses removed from the sur- 
face of the ulcer and examined with the microscope are found to 
be full of the aspergillus fumigatus. It may usually be ascer- 
tained that an injury has preceded the appearance of the 
ulcer. 

Treatment. — The membranous mass which forms the floor 
of the ulcer should be peeled off, and the underlying surface 
cauterized and dressed with xeroform, after which a good and 
rapid cure takes place. 

(6) Non-Ulcerative Inflammations of the Cornea. — 
Abscess. — This affection is on the borderland between the ul- 
cerative and non-ulcerative inflammations of the cornea ; for in 
one case it will result in an ulcer — usually the ulcus serpens — 
while again it will run its course without ulceration. The ab- 
scesses which are seated in the more superficial layers are those 
which go on to ulceration ; those in the deeper layers are less likely 
to do so. 

Abscess differs from infiltration in that the pus which forms 
it destroys the true corneal tissue — ^the fibrill^ and fixed cor- 
puscles — and does not merely lie between them 

14 



i62 DISEASES OF THE EYE. 

Signs and Symptoms. — The appearance presented is that of 
a yellowish circumscribed opacity, more intense at its margin 
than at its center, seated at or near the middle of the cornea, and 
surroimded by a light gray zone. It is usually round in shape, 
but when situated near the edge of the cornea it is apt to be 
crescentic. The surface of the cornea just over the abscess is 
at first a little elevated over the general surface, but later on 
becomes flattened, owing to a falling-in of the normal layers an- 
terior to the abscess ; and the epithelium of the flattened part 
has a dull, breathed-on look. The rest of the cornea may also 
lose its brilliancy, although in a much less degree. Hypopyon 
and iritis are constant attendants upon corneal abscess. There is 
much injection of the conjunctival and ciliary blood-vessels. Se- 
vere pain in and about the eye and blepharospasm are common, 
yet occasionally a corneal abscess will be attended by but little 
pain or irritation. 

Progress. — The abscess spreads through the cornea, usually in 
some one direction, and this direction is indicated by the yellow- 
ish opacity being more intense at the advancing side of the ab- 
scess. Before long, if the abscess be superficial, the layers of 
cornea covering it come away, and the condition is changed into 
that of the ulcus serpens already described. The deeper ab- 
scesses spread through the cornea more or less widely, and ulti- 
mately become absorbed, without having caused ulceration. But 
even these abscesses leave considerable opacity behind. The 
process which ends in ulceration is the more common of the 
two. 

Etiology. — Abscess is the result of infection of the cornea 
with pyogenic organisms, which reach it either from without, 
through some traumatic loss of substance of the corneal epithelium, 
or from within, by the agency of the blood. The micro-organisms, 
which are introduced through a superficial loss of substance, may 
either have been on the foreign body which produced the injury, 
or they may have been present in the conjunctival sac. Infection 
through the blood is occasionally seen in some acute exanthematous 
diseases, such as scarlatina, measles, and smallpox ; more especially 
in the latter in its convalescent stage. 

Treatment. — Atropin, warm fomentations, and a bandage. But 
if these mild measures do not in a day or so arrest the progress of 
the abscess, resort nuist be had to the actual cautery. 

Diffuse Interstitial, or Parenchymatous, Keratitis. — This af- 



THE CORNEA. 163 

fection occurs most commonly between the ages of five and fifteen. 
It usually commences at some one part of the margin as a light 
grayish opacity, accompanied by slight injection of the ciliary ves- 
sels. The rest of the corneal margin soon becomes similarly 
affected ; and then gradually the opacity extends concentrically into 
the cornea, or does so by sending in processes which afterwards 
become confluent. In this way the whole cornea becomes affected 
by degrees ; and its epithelium acquires the breathed-on or ground- 
glass appearance, which is seen, also, in acute glaucoma. Occa- 
sionally the opacity commences at the center, and not at the mar- 
gin of the cornea, as small gray spots, and extends towards the 
margin, which it often does not reach before clearing com- 
mences. 

The opacity lies in the deep layers of the true cornea, and is 
slightly more intense in spots here and there. It is sometimes 
only a very light cloud, while again the cornea may be so opaque 
as to render the iris quite invisible. Along with the opacity, ves- 
sels form in the cornea in its posterior layers, but the degree of 
vascularization varies very much in different cases. In some the 
presence of vessels can only be ascertained by careful examination 
with a high convex glass ( + 16.0) behind the ophthalmoscope, or 
with the corneal microscope; while in others the new vessels are 
present in great numbers, and can be readily seen with the naked 
eye. In other cases, again, close leashes of vessels follow the 
tongues of opacity into the cornea, giving rise to the appearance 
known as the '' salmon patch." 

The infinite variety in the degree of opacity and in the amount 
and arrangement of the vascularization results in a great variety 
of the appearances in different cases. When the whole cornea 
has become opaque it begins to clear up at the margin, and the 
central portion becomes even more opaque than the margin had 
ever been — a fact which shows that the very cells which entered 
the cornea at its margin have advanced to its center. The clear 
margin gradually increases in width until only a rather intense 
central opacity is left. This central opacity slowly breaks up, 
and becomes absorbed, but not always completely; and then con- 
siderable and permanent impairment of vision may remain. 

In severe cases iritis and chorioiditis are nearly always present, 
although the latter is not observable until the cornea has become 
clear enough to admit of an ophthalmoscopic examination. The 
disease, indeed, must be regarded, strictly speaking, as one of the 



i64 DISEASES OF THE EYE. 

uveal tract, to which the posterior layers of the cornea, which are 
mainly diseased, belong. 

The two forms above described, one commencing at the margin, 
the other at the center of the cornea, and more or less vascularized, 
but for the most part ultimately occupying the entire cornea, are 
those we are wont to find in children and young adults, and which, 
as will just now be stated, have congenital syphilis as their usual 
cause. But in older persons, up to thirty or thirty-five, milder 
forms of interstitial keratitis are met with. These rarely occupy 
more than a small region of the cornea, generally towards its 
center, either as a patch or as a ring of opacity, and with little or 
no vascularization. 

The affection is often accompanied by a good deal of pain and 
blepharospasm, especially in the severe vascular forms, and there, 
too, the tension of the eye is apt to be temporarily reduced. 

The acute stage of the disease lasts from six to eight weeks, or 
longer. But the entire process may not be completed for many 
months, and in one case which I saw the opacity did not begin to 
clear away for eleven months after the cornea was first attacked, 
the whole process extending over a period of two years. 

Both eyes invariably become affected, although not always at 
the same time, the second eye being often not attacked until the 
inflammation in the first has made some progress, or, perhaps, not 
until it has undergone cure. It is important, in the very com- 
mencement of treatment, to acquaint the patient or his parents with 
the likelihood of this course of events. 

In adults usualh^ one eye alone is attacked, iritis is rare, the 
duration of the process is comparatively short, and complete clear- 
ing up is relatively frequent. 

Causes. — The affection is more common in girls than in boys, 
and most frequently appears during second dentition, when the 
upper incisors are being cut, or at puberty. It depends upon some 
serious derangement of the general nutrition ; and this, in over 50 
per cent, of the cases, is inherited syphilis — a fact which was first 
pointed out by Mr. Jonathan Hutchinson. The children are often 
thin, anemic, and of stunted growth, with flat nose, cicatrices at 
the angles of the mouth, often more or less deaf ; and the peculiari- 
ties of the incisor teeth, so well known from Mr. Hutchinson's de- 
scription, are present in about one-half of the cases. 

Occurring in adults, the affection is rarely due to inherited 
syphilis, although acquired lues may sometimes be taken as its 



THE CORNEA. 165 

cause ; while, again, it will often be impossible to assign any origin 
for it other than the universal one of exposure to cold, etc. Pos- 
sibly some cases are due to tubercular disease. 

Prognosis. — In children — in view of the possibility of an in- 
complete clearing of the cornea and the irregularity of its surface 
which the process may cause, as well as of the serious complica- 
tions liable to supervene, and which may completely annihilate 
vision — the prognosis must be guarded (although by no means 
hopeless) in those cases where the opacity is very intense, or where 
there is much vascularity. Yet in the milder cases a very favor- 
able prognosis may be given. I have never seen the affection 
recur, but it is said to do so very rarely. 

In adults, as stated, the prognosis is much more favorable. 

Treatment. — In the early stages no irritants should be locally 
applied. Atropin is important for the prevention of iritis or of 
posterior synechiae ; and the use of radiant heat, in the form of hot 
poultices or fomentations, or the Japanese warmer, promotes the 
nutrition of the cornea and hastens the cure by absorption of the 
cellular elements which form the opacity. A bandage should be 
worn. When the acute stage is ended the yellow oxid ointment 
may be employed with benefit for stimulating the absorbents to 
carry off what remains of the opacity. Massage may be used with 
advantage in both stages to disperse the infiltration. In severe 
cases I would advise a course of mercurial inunctions, continued 
for several weeks, care being taken not to allow stomatitis to ex- 
ceed very moderate bounds. In mild cases a tonic plan of 
treatment, with iodid of iron and cod-liver oil, is the most 
suitable. 

Counter-irritation, in the form of blisters to the temple or a 
seton in the scalp, is extensively employed by some surgeons. I 
have never adopted this treatment, as I doubt its value and am 
loath to add a worry to the troubles inseparable from so weari- 
some a disease. 

Keratitis Profunda. — This also is an interstitial or parenchy- 
matous keratitis. It presents the appearance of a grayish opacity 
in the deep layers of the cornea at or near its center, which gradua- 
ally increases in intensity and extent, but never reaches the margin 
of the cornea. The epithelium of the cornea over the infiltration 
is dull. There is but little vascularization and no great tendency 
to inflammation of the uveal tract. After some weeks the infiltra- 
tion gradually breaks up and becomes absorbed, leaving in severe 



i66 DISEASES OF THE EYE. 

cases a good deal of opacity, and in less severe cases a fairly clear 
cornea. The afifection is seen only in adults, and its etiology is 
unknown. It seems probable that it is the result of a localized 
derangement of the posterior epithelium of the cornea ;^^ but if 
that be so, the ultimate cause of that derangement has not yet been 
suggested. 

Treatment. — Atropin, warm fomentations, and bandage, with 
care of the general health. 

Grating-like Keratitis. — This rare disease was described by 
Haab.^^ Its presence is very apt to be overlooked in the early 
stages, for by focal illumination the cornea may seem perfectly 
normal, and the rest of the eye, except perhaps for some slight 
distention of the anterior ciliary and larger conjunctival vessels, 
is healthy, and is not irritable. The patient complains of slight 
burning sensations (especially during use for near work), of some 
photophobia, and of somewhat diminished acuteness of vision. 
Transmitted light from the mirror displays in the illuminated 
pupillary area a number of fine radiating forked lines, recalling 
somewhat the appearance in some incipient cataracts, and between 
these lines there are innumerable fine dots. With the corneal 
microscope these dots and lines are found to be grayish, and to be 
situated closely under the epithelium. The surface of the latter is 
at this period in no way altered. A zone 2 or 3 mm. in width in- 
side the corneal margin is quite free from both lines and dots, while 
the central region is occupied by dots alone, and contains no radiat- 
ing lines. The latter are present in the intermediate zone only. In 
the further progress of the disease the lines advance into the center 
of the cornea, and the gray dots increase in number, the anterior 
ciliary vessels are more distended, vision sinks lower, and the 
patient may occasionally complain of some pain, with lacrimation, 
and swelling of the eyelids ; but more commonly there is no irrita- 
tion. The lines and dots now begin to show as slight elevations 
on the surface of the cornea, although under the epithelium, and 
the arrangement of the radiating forked lines begins to resemble 
the appearance of an iron grating. At a still later period the 
opacity in the center of the cornea becomes more intense and may 
even be leukomatous, while a marginal zone of the cornea remains 
fairly clear. Owing to the difficulty of distinguishing lines and 
dots, the diagnosis at this advanced stage may again be rendered 
doubtful, and the appearance is apt to be confused with that left in 
some severe cases of diffuse parenchymatous keratitis. 



THE CORNEA. 167 

It is probable that the changes which produce the appearances 
described above commence in Bowman's layer, and consist in a 
hyaline degeneration of it, and that this process subsequently ex- 
tends to somewhat deeper layers. The disease is apt to be found 
in more than one member and generation of a family. No consti- 
tutional or other cause can be assigned to it. It seems as a rule to 
commence in youth — in the fifteenth to twentieth year or there- 
abouts — and to progress slowly in both eyes during many years, 
leaving the patient almost blind in middle life. 

Treatment is practically useless. Yellow oxid of mercury oint- 
ment has been employed, and warm fomentations, also galvanism, 
and hydrate of chloral eye-drops. 

Guttate Keratitis. — This is a very similar disease to the fore- 
going, and, when our experience is greater, may prove to be one 
and the same with it. It was described by Groenow.^" It differs 
from the grating-like keratitis in that no radiating lines are present 
in the cornea, but small gray patches and fine dots only. The 
small patches are of all shapes, and occupy the central region of 
the cornea, while the fine dots are present in every part, but more 
abundantly towards the center than elsewhere. These patches 
and dots lie in the most anterior layers of the cornea, and the epi- 
thelium over them becomes raised, giving an uneven and dull ap- 
pearance to the corneal surface. Both eyes are affected. Pain or 
other irritation is almost absent. Most of the cases observed have 
been in men, and usually in young men. The cause is unknown. 
No relation to syphilis or other constitutional condition has been 
made out. Fuchs ascertained that the seat of the mischief is in 
those corneal cells which lie between the deeper and superficial 
layers, and which he found to contain mucin. Like grating-like 
keratitis, this is an exceedingly chronic disease, lasting many 
years, and finally causing much loss of sight. Similarly, too, it 
may so far be said to be incurable. 

Keratitis Punctata. — Until recent years this term was only 
given to a condition which occurs in cyclitis, in iridocyclitis, and 
in sympathetic ophthalmitis, and which is not a primary disease 
of the cornea, and therefore does not come within the scope of this 
chapter. It will be considered under those headings (chap, x.) ; 
and it need only here be stated that it consists in the deposit, in the 
form of fine dots on the back of the cornea, of lymph derived from 
inflamed portions of the uveal tract, mainly from the inflamed 
ciliary processes. 



i68 DISEASES OF THE EYE. 

Fuchs ^^ has described a form of keratitis which he terms 
Keratitis punctata superficialis, and which has a good claim to that 
name. It begins with the symptoms of an acute conjunctivitis. 
Either at the same time, or some days or weeks afterwards, minute 
gray spots may be seen in the superficial layers of the cornea, the 
epithelium over the spots being somewhat raised up. The spots 
are often arranged in groups or rows, and may be scattered over 
nearly the entire cornea, or else confined to its central region. 
There may be but a few of them, or there may be a hundred or 
more, and one or both eyes may be afifected. The initial irritative 
symptoms soon disappear; but the spots themselves remain for 
many weeks, or longer, and finally fade away entirely. It is more 
common in young people than in later life, and occurs usually in 
connection with a catarrh of the air passages ; but it must not, by 
reason of this, be confounded with herpes of the cornea. The 
spots are often very faint, and hence can easily be overlooked, un- 
less searched for with the oblique light. In this country the affec- 
tion is rather rare, but I have seen several cases of it. 

The Treatment should consist in atropin, bandage, and warm 
fomentations. 

Sclerotizing Opacity of the cornea sometimes complicates 
scleritis, affecting the margin of the cornea in the neighborhood 
of the scleral affection, but not extending more than 2 to 3 mm. 
into the cornea, except in very severe cases. It is an intense white 
opacity situated in the true cornea, and is apt to remain as a per- 
manent opacity, even when the scleritis undergoes cure. In such 
cases of sclero-keratitis iritis is often present. 

Treatment. — Warm fomentations, massage, and the treatment 
of whatever diathesis (rheumatism, syphilis) may be taken as giv- 
ing rise to the scleritis. 

Ribandlike Keratitis (Transverse Calcareous Film of the Cor- 
nea; Calcareous Film of the Cornea). — This is a degenerative 
alteration which occurs chiefly in the cornese of eyes destroyed by 
severe intra-ocular processes, such as iridocyclitis, sympathetic 
ophthalmitis, glaucoma, etc. 

It also occasionally occurs as a primary disease in some persons 
of advanced life. In these latter instances glaucoma often comes 
on at a later period, or the corneal disease may be followed by 
iridocyclitis, or central chorioiditis. It seems probable that in 
these primary cases the cause of the degeneration is simply a loss 
of vital energy in the corneal tissue, due, it may be, to vascular 



THE CORNEA. 169 

changes. These latter, in their turn, are held by Nettleship to be 
due in many instances to gout. 

The disease occupies that transverse strip of the cornea which is 
uncovered in the commissure of the eyelids during waking. It 
usually commences on the inner margin of the cornea, but soon 
appears at the outer margin, and advances from each direction 
towards the center, where the two sections join. It presents the 
appearance of a grayish-brown opacity, with, in most cases, white 
calcareous deposits in and under the epithelium. In blind eyes 
which are constantly rolled upwards, the opacity is found not in 
the central transverse section of the cornea, but in the exposed 
lower third. The opaque masses consist of carbonate and phos- 
phate of lime. Leber puts forward ^* the view that an abnormally 
abundant supply of phosphate of lime in the blood, and nutritive 
fljaid of the cornea, is the cause of this condition, the rapid evapo- 





Fig. 56 — (Pagensfccher). Fig. 57 — (Pagenstecher). 

ration on the exposed part of the cornea being the reason why the 
deposit takes place there. The deposit is at first in Bowman's 
membrane, but later on it may appear in the anterior layer of the 
true cornea, and in the epithelium. 

Treatment. — Some improvement may be effected by scraping 
away the chalky deposit. 

ECTASIES OF THE CoRNEA. 

Staphyloma of the Cornea is the result of a perforating ulcer 
of the cornea. The ulcer, having healed, may present a weak 
cicatrix, which becomes bulged forw^ards by even the normal intra- 
ocular tension (Figs. 56 and 57). If the iris be not involved in 
this cicatrix the anterior chamber will be made deeper (Fig. 57). 

Staphyloma corneae, in which the iris is involved, is probably a 



lyo DISEASES OF THE EYE. 

more common condition than the above. When a corneal ulcer is 
large, a correspondingly large portion of iris is liable to become 
prolapsed into it, and to form a bulging mass. This may burst 
and collapse, and a flat cicatrix may be formed ; or, if it do not 
rupture, it may form what is termed a partial staphyloma of the 
cornea and iris, the latter becoming consolidated by the formation 
of a layer of connective tissue over it. 

If the whole, or a very large part, of the cornea be destroyed by 
an ulcer, the iris is completely exposed. It soon begins to be cov- 
ered with a layer of lymph, which gradually becomes converted 
into an opaque cicatricial membrane. Should this not be strong, 
the normal intra-ocular tension is sufficient after a time to make 
it bulge ; or, increased intra-ocular tension may arise in consequence 
of further changes within the eye, and then bulging of the pseudo- 
cornea all the more surely comes on, and the condition is termed 
total staphyloma of the cornea. Sometimes a total staphyloma 
has a lobulated appearance, owing to the pseudo-cornea having 
some of its fibers stronger than others, and hence the name given 
to the condition {ivomryTaq)t^^f},a bunch of grapes), and which 
has in time become applicable to almost any bulging of the cornea 
or sclerotic. Such staphylomata are apt to gradually increase to 
a very large size. 

Treatment. — In cases of partial staphyloma, where a clear por- 
tion of the cornea remains, an iridectomy is frequently indicated 
for the reduction of the tension — so that further bulging may be 
arrested — as well as for the sake of the artificial pupil, which may 
improve sight, in cases where the normal pupil is obliterated by 
corneal opacity. When, sight having been lost, the staphyloma is 
very bulging, or when total staphyloma is present, enucleation of 
the eyeball, or one of the following operative measures, must be 
adopted. 

Abscission. — A Beer's cataract knife being passed through the 
base of the staphyloma, with its edge directed upwards, the upper 
two-thirds of the staphyloma are separated off, while the remain- 
ing third is detached by means of a scissors. If the lens be present 
it must now be removed. The wide opening becomes filled up 
with granulations and cicatrizes over. 

In de Wecker's ^^ method the opening is closed with con- 
junctival sutures. He begins the operation by separating the 
conjunctiva all round the margin of the cornea, and by then loos- 
ening it from the eyeball nearly as far back as its equator. Four 



THE CORNEA. 



171 



sutures (a, b, c, d) of different colors are then passed through the 
conjunctiva about 2 to 3 mm. from the margin of the wound, as 
represented in Fig. 58. In order to keep the field of operation 
clear the ends of two of these sutures are laid over on the nose 
while the others are laid over on the temple. The staphyloma is 
now abscised, and the sutures drawn together and tied. 

The foregoing and other methods of abscission are only applica- 
ble where the tension is either low or normal. If it be high, the 
liability to intra-ocular hemorrhage during the operation makes 
enucleation, evisceration, or Mules' operation more suitable pro- 




FiG. 58. 



ceedings. Indeed I, and probably most surgeons, would now em- 
ploy one of the two latter operations in all these cases. 

Evisceration was proposed about the same time by Professor 
Graefe, of Halle,^*^ to prevent death from meningitis after the re- 
moval of suppurating globes, and by Mules,^^ of Manchester, 
chiefly to take the place of enucleation in cases of sympathetic 
ophthalmitis. Many surgeons are opposed to its employment in 
those cases, but for staphyloma of the cornea it cannot meet with 
any such opposition. 

The cornea is removed by making an incision with a Graefe's 
knife, so as to include one-half of the corneo-scleral margin, and 
by completing the circumcision with scissors. All the contents 
of the globe are then evacuated by means of Mules' scoop, care 



1/2 DISEASES OF THE EYE. 

being taken to remove the chorioid unbroken by carefully peeling 
it from the sclerotic margin backwards, until it is only held at the 
lamina cribrosa. The scoop is then used to lift out the separated 
unbroken chorioid and then other contents of the globe. 

Finally, the margins of the sclero-conjunctival wound are drawn 
together with a few points of suture. The whole proceeding 
should be done with strict antiseptic precautions, chief among 
which is the free use of irrigation with a i in 5000 solution of cor- 
rosive sublimate before, during, and after the operation, the in- 
terior of the globe being most carefully washed out with the solu- 
tion in a full stream. The result is a fairly good and freely mov- 
able stump for the application of an artificial eye. 

Mules' Operation. — This proceeding — a modification of the 
foregoing — was also proposed by Mules ^^ for cases of threatened 
sympathetic ophthalmitis, and, like simple evisceration, has not yet 
met with universal acceptance in those cases, because many fear 
that it does not afiford sufficient protection against sympathetic 
ophthalmitis. I do not altogether participate in this feeling. In 
cases of staphyloma, however, and in some other conditions where 
the questions of sympathetic ophthalmitis in the other eye, or of a 
new growth in the eye to be operated on, do not enter into con- 
sideration, no proceeding is, in my opinion, more satisfactory, at 
least in young persons, than this beautiful one of Mules'. The 
prothesis it gives is almost perfect. Its object is to provide a still 
better stump for the artificial eye by the insertion into the scleral 
cavity of a hollow glass ball, called an artificial vitreous humor. 
It is performed as follows : 

The cornea is removed — the conjunctiva having first been freed 
from the scleral edge towards the equator of the eyeball — and the 
contents of the eyeball evacuated, as in simple evisceration. The 
opening is now enlarged vertically, to admit of the introduction of 
one of the glass spheres. This introduction is best effected by 
means of a special instrument designed for the purpose by Mules. 
The spheres are made in several sizes to suit different cases, and it 
is well not to use the largest which will fit into any given eye. The 
sphere having been inserted, the margins of the sclerotic opening 
are united vertically by some points of interrupted suture, for 
which purpose I prefer silk to catgut, as the latter is apt to undergo 
absorption before complete union has taken place. The con- 
junctival opening is then closed by another set of sutures placed 
at right angles to the sclerotic line of closure. Similar antiseptic 



THE CORNEA. 173 

precautions are required as in simple evisceration, and care must 
be taken that all bleeding in the cavity has ceased before the glass 
sphere is inserted. Before the lids are closed the anterior surface 
of the globe is well covered with boric acid or xeroform. A firm 
antiseptic bandage is applied. I do not dress the eye for forty- 
eight hours, and subsequently once every twenty-four hours, using 
the sublimate solution freely. There is generally some reaction, 
consisting of chemosis, swelling of the eyelids, and pain, and some- 
times these symptoms are very marked, especially if too large a 
sphere has been employed. In the course of a week or so this all 
passes off, and a very perfect stump is obtained. 

The danger that the glass sphere may get broken by a blow 
upon the eye has been put forward as an objection to this method. 
No doubt it is an accident which may occur, and would then ne- 
cessitate the enucleation of the eye ; but no case of the kind has as 
yet been recorded, although the operation has been in use for 




Fig. 59. 

eighteen years. Silver spheres, instead of those of glass, have 
been sometimes employed to obviate the danger referred to. 

I can recommend this procedure, and I use it frequently. \Mth 
a well-fitting glass eye, the cosmetic result it gives is infinitely 
better than that produced either by complete enucleation or by 
evisceration of the eyeball. It is, I think, more uniformly suc- 
cessful in young people than at more advanced ages, and, there- 
fore, I do not recommend it for persons over twenty-five. To 
insure success an important point is to take care that the glass 
globe be not too large — it should be an easy fit for the cavity of 
the sclerotic. In case the sutures give way, and the sclerotic 
opening gapes, an attempt may be made to reclose it with new 
sutures, but the attempt is not often successful. As a rule the 
glass globe must in that event be removed, and the case then be- 
comes one of simple evisceration. 

Conical Cornea, or Keratoconus. — In this the cornea is al- 



1 74 DISEASES OF THE EYE. 

tered in shape to that of a cone. The change is due to a gradual 
and slowly advancing atrophic process in the cornea, at or near 
its center, in consequence of which the normal intra-ocular tension 
acts on it so as to distort it into the form represented in Fig. 59. 
If the apex be touched with a probe its extreme thinness may be 
ascertained. Tweedy ^^ holds that there may be some congenital 
weakness in the center of the cornea as the result of its mode of 
development, while Panas ^^ and Elschning ^^ are disposed to seek 
the cause of keratoconus in a chronic degeneration of the mem- 
brane of Descemet. The cornea remains clear, except sometimes 
just at the apex of the cone, where a slight nebula may be present. 
The position of the apex of the cone is often not quite central, and 
is then most commonly either in the lower outer or lower inner 
quadrant of the pupil. The condition is easy of diagnosis in its 
advanced stages by mere inspection of the cornea, especially in 
profile, but in its commencement it may not be so readily de- 
tected. 

In the early stages, when light is thrown on the cornea from 
the ophthalmoscope mirror, as in retinoscopy, the corneal reflex 
will be noticed to be smaller at the center, owing to the greater 
curvature there. Moreover, a dark shadow, circular or crescentic 
in shape according to the incidence of the light, appears between 
the corneal margin and the corneal center; and, finally, when the 
fundus is examined its details will be seen distorted. 

The process begins in early adult life, progresses slowly, never 
leads to rupture or ulceration of the cornea, and, finally, after many 
years, ceases to progress, but does not undergo cure. Both eyes 
are apt to become attacked, one after the other. The disturbance 
of vision is very great, owing to the extreme irregular astigmatism 
produced. 

Treatment. — In the early stages, or in slight cases, an improve- 
ment in vision may be obtained by means of concave, spherical, or 
sphero-cylindrical glasses ; for, as is evident, the change in shape of 
the cornea must cause the eye to become myopic. The refraction of 
the central portion of the cornea may be ascertained by retinoscopy, 
with the aid of a stenopeic disc in the trial frame, as recommended 
by Mackay.^^ At a later period these glasses are of little use. 
Hyperbolic lenses have been employed, but, although they may 
raise the acuteness of vision, there are obvious difficulties in the 
way of the practical every-day use of them. A stenopeic slit ren- 
ders assistance in some cases. 



THE CORNEA. 175 

Glass shells, which are known as contact glasses, have been 
introduced by Fick for the temporary relief of irregular refrac- 
tion ; they are worn in contact with the eye, and may enable some 
patients to work for hours at employments which they could not 
otherwise carry on. 

A few cases are reported in which the keratoconus was much 
reduced and vision greatly bettered by instillations of eserin and 
the application of a pressure bandage, continued for several 
months. 

But it is upon operative measures we must chiefly rely in this 
affection for any practically useful improvement in sight. 

Von Graefe's Method consists in flattening the cornea by the 
production of an ulcer on the apex of the cone, and the result- 
ing cicatricial contraction. From the surface of the cornea, a 
little to one side of the apex of the cone, a morsel of corneal sub- 
stance is removed with a cataract knife, care being taken not to 
open the anterior chamber. On the second day after this proceed- 
ing the wound is touched with mitigated lapis (solid), and this is 
repeated every third day for a fortnight or three weeks. Para- 
centesis of the anterior chamber is then performed through the 
floor of the ulcer, and the aqueous humor is evacuated every sec- 
ond day for a week, after which the healing process is allowed 
to take its course. A bandage must be worn during the whole 
course of the treatment. Finally, when the contraction and conse- 
quent flattening are completed, a narrow optical iridectomy may 
be necessary, in consequence of the central, or almost central, and 
rather intense corneal opacity. 

In Bader's Method a small elliptical flap of the cornea at its 
apex is removed, and the margins are brought together by one 
or two fine sutures. The sutures are omitted by many surgeons as 
useless, and as liable to cause irritation. Opinion is divided as 
to whether the ellipse should lie vertically or horizontally in the 
cornea. An anterior synechia is unavoidable in a large number of 
the cases, and a subsequent optical iridectomy is always required. 
I have myself no experience of this operation, but it is said to be 
attended with unusual risk of suppuration of the cornea, going on 
to destruction of sight. 

Sir William Bowman's Method consisted in cutting a disc on 
the apex of the cornea with a small trephine, and then severing 
this disc with forceps and cataract knife. Cicatrization of the 
wound produces the desired flattening of the cone. 



176 DISEASES OF THE EYE. 

Mr. Stanford Morton informs me that he employs, with satis- 
factory results, a modification of an operation described by Hig- 
gins.^^ He excises an elliptical piece from the apex of the cone 
by transfixing it from above downwards, about midway between 
its base and apex, with a long narrow rigid Graefe's knife, of 
which the edge is directed forwards and inclined slightly 
to the right. The knife is pushed onwards until it cuts its 
way out a little to the right of the apex of the cone, the aque- 
ous escaping at the same time. The flap thus formed is then 
lifted up well by a fine forceps, and the knife — with its edge 
now turned to the left — is passed beneath the points of the forceps, 
end by cutting forwards the flap is excised. The sides of the 
wound should be steep and incline towards each other at an 
angle of 30° to 45°. The apex of the cone being usually some- 
what downwards and inwards, or outwards, from the center of the 
cornea, it is important, in order to prevent an anterior synechia, to 
avoid carrying the incision too far downwards. The eye should 
be well soaked with atropin both before and after the operation, 
and a firm compress kept on for some time after the wound has 
healed. 

Multiple puncturings of the apex of the cone with a fine cat- 
aract needle have been employed. The summit of the cone is 
transfixed from three to six times at each sitting, and this may 
be repeated at intervals of two weeks or more. The first effect 
of the punctures is to allow some of the aqueous humor to es- 
cape, and then the eye is firmly supported v/ith a bandage. The 
pupil is kept under the influence of eserin. Eventually a network 
of cicatricial tissue forms, which flattens the cone without giving 
rise to much corneal opacity. 

A satisfactory proceeding, and one now very generally adopted, 
is the application of the electro- or thermo-cautery at a red heat 
to the apex of the cone. By this means a contracting cicatrix is 
produced, which brings about a general flattening of the cornea, 
while the operation is practically free from risk. The cauteriza- 
tion must be strictly confined to a small area at the apex of the 
cone, and the. cornea should not be perforated with the cautery. 
The operation may be repeated over the same area at intervals 
of ten to fourteen days, to bring about a more intense cicatrix. 

Sir A. Critchett lays much stress on the graduated application 
of the cautery. He first applies the cautery at a black heat to the 
whole area intended to be cicatrized ; within this area a little more 



' • THE CORNEA, 177 

is destroyed at a slightly increased heat, while the very apex is 
touched with a cautery at a dull red heat. One sitting is suffi- 
cient. 

After the cicatrization following on cauterization is completed, 
the scar is to be tattooed, and an optical iridectomy will usually 
be required, especially if the cone has been quite central. The 
cases in which the apex of the cone has an eccentric position are 
those most benefited by cauterization, because the resulting scar 
interferes less with vision than where it is central. 

Tumors of the Cornea. 

Primary tumors of the cornea are extremely rare. Epithelioma 
and sarcoma have their origin not in the cornea, but in the limbus 
conjunctivae (p. 129). Dermoid tumors are usually seated 
partly on the conjunctiva and parth' on the cornea (p. 128). Yet 
a very few cases of papilloma, epithelioma, and fibroma are re- 
corded as taking their origin in the cornea. Corneal cysts also 
occur. 

Injuries of the Cornea. 

Foreign Bodies in the Cornea, such as morsels of iron, stone, 
coal, etc., are amongst the most common accidents of the entire 
body. The pain caused by these foreign bodies is very con- 
siderable, as can be understood, when the rich nerve supply of the 
cornea is remembered. 

The dangers which may follow on the presence of a foreign 
body in the cornea depend partly upon the infection or non-infec- 
tion of the foreign body, and partly upon the depth at which it is 
buried in the cornea. The deeper a foreign body lies the more 
difficult will be its removal, and the greater must be the laceration 
of the cornea caused by its removal. A foreign body which carries 
infection will be more likely to set up serious inflammatory reac- 
tion than one which is aseptic or nearly so. For this reason it is 
important to ascertain, if possible, the origin of the foreign body, 
although an apparently aseptic origin must not set all fear on this 
point at rest. Atoms of hot metal are from their temperature 
aseptic. 

Many foreign bodies are so small as to defy detection until the 
cornea is searched with the oblique light — an aid which should al- 



178 DISEASES OF THE EYE. 

ways be made use of whenever the symptoms or history in the re- 
motest way suggest the presence of a foreign body. 

A foreign body which Hes quite superficially in the epithelium 
is easily removed by gentle wiping with a clean camers-hair pencil, 
or soft cloth. Those which lie deeper require instrumental inter- 
ference. 

The eye having been thoroughly cocainized, the patient is seated, 
and leans his head against the chest of the surgeon, who stands 
behind him. With the index-finger of the left hand the surgeon 
then lifts the upper lid of the injured eye, pressing the margin 
of the lid upwards and backwards, while with the second finger 
he d.epresses the lower lid in a similar manner ; and between these 
two fingers he can, to a great extent, control the motions of the 
eyeball. The foreign body is now to be pricked out of the cornea 
with a special needle, with as little injury of the general sur- 
face as possible, the patient all the while directing his gaze steadily 
at some given point. If the foreign body be deep in the layers of 
the cornea, it must be dug out, as it were; and a minute gouge 
is made for this purpose. In the case of a morsel of iron or 
steel which has lain for some time in the cornea, a small ring of 
rust will be seen surrounding the late seat of the foreign body 
after its removal. This rust-ring is in the true cornea, and must 
be carefully scratched away, or the recovery, by necrosis of the 
affected part, will be much slower, and the resulting opacity much 
greater. 

Care must be taken not to infect the cornea in the removal 
of a foreign body, and, consequently, thorough antiseptic precau- 
tions, especially as regards the instrument used, must be taken. 
After the foreign body is removed, the place where it was seated 
should be washed with a i in 5000 solution of corrosive sublimate. 
A bandage is worn until the epithelium is regenerated — /. e., for a 
day or two. 

Every surgeon and general practitioner should possess the two 
small instruments required for the removal of superficial corneal 
foreign bodies, and should understand the use of them. 

The magnet is of no use whatever for the removal even of 
superficially seated foreign bodies of steel or iron in the cornea. 

Sometimes a foreign body in the cornea will be so long as to 
protrude somewhat into the anterior chamber, and there is langer 
that, in the attempts at removal, it may be pushed farther on, and 
fall into the anterior chamber. Here it is necessary to pass a 



THE CORNEA. 179 

keratome through the cornea, and behind the foreign body, so as 
to provide a firm base against which to work, or the keratome 
may be made to push the foreign body forwards. 

The wing-cases of small beetles and scales of seeds may get 
into the eye, and adhere to the cornea by their concave surface for 
several days. 

Simple Losses of Substance or Abrasions of the surface of the 
cornea, involving the most anterior layers of the true cornea, or 
perhaps merely the epithelium, are very common from rubs or 
scratches with branches of trees, finger-nails, etc., etc. These in- 
juries heal readily by protecting the eye with a bandage ; but when 
neglected, or if septic matter have been introduced when the 
injury occurred, or if it be present in the conjunctiva or lacrimal 
sac, these losses of substance are capable of forming the starting- 
point of corneal abscess (p. 161), ulcus serpens (p. 151), etc. 

A remarkable condition known as Recurrent Abrasion, or 
Disjunction of the Cornea (and also as Traumatic Keratalgia, 
and Recurrent Traumatic Keratalgia) is sometimes observed to 
follow upon abrasions of the cornea. Healing of the primary 
lesion having taken place in an apparently normal manner, the 
patient, after an interval of days, weeks, or even months, is seized 
with severe pain, similar to that experienced on the occasion of 
the injury, on awakening in the morning. On examination of 
the eye a loss of the epithelium, which may be greater or less in 
extent than was the primary loss, is found at the seat of the 
original lesion, or it may be elsewhere on the cornea. Or, more 
rarely, instead of a loss of epithelium, the latter may be raised 
up like a vesicle, or bulla. Examination of such cases has shown 
that the epithelial covering of the whole cornea may easily be lifted 
off with a forceps ; in short, that the cohesion between epithelium 
and Bowman's membrane all over the cornea has become im- 
perfect. Care of the eye by means of a bandage enables the re- 
newed loss of substance to be rapidly repaired ; but after a period 
of quiescence, another attack takes place on awaking in the morn- 
ing or in the course of the night, and such attacks may continue to 
recur even for several years. It is characteristic of the affec- 
tion that the attacks always take place on awaking — a circum- 
stance which is explained by the slight adhesion between palpebral 
conjunctiva and corneal epithelium formed during sleep, so that 
on the lifting of the eyelid the loosened epithelium is torn away 
or lifted in a bulla-like shape. Examination of the corneal sur- 



i8o DISEASES OF THE EYE. 

face, after one of these attacks, by the usual methods (focal il- 
lumination with magnifying glass, and fluorescin), may fail to 
reveal the presence of a loss of substance, and then, according to 
Szili,-* it may be discovered by means of transmitted light 
from a plane mirror, which will display the defect as a black 
mark. 

The cause of disjunction of the cornea has not been ascer- 
tained. The condition has occasionally been noted in cases where 
no trauma had occurred, and this suggests the possibility of the 
eyes in the traumatic cases being such as already had a tendency 
to the derangement, whatever it may be, and which became ag- 
gravated by the injury. 

Schoeler -^ suggests that the tendency to recurrence is due to 
very minute foreign bodies, which lie on the surface of the 
original loss of substance when the epithelium grows over it, and 
prevents a correct adaptation of the epithelium to Bowman's mem- 
brane, between which the tears are consequently enabled to per- 
colate, and to separate off the epithelium even to a greater ex- 
tent than did the original trauma. 

Treatment. — Cocain, owing to the disorganizing effect it has 
on the corneal epithelium, should be used as sparingly as possible. 
A carefully applied bandage is important, and Szili states he has 
found dionin useful. He also has used in many cases an oper- 
ative measure — namely, the removal with the forceps of the entire 
corneal epithelium or as much of it as would easily come away. 
He believes that this has had the effect of inducing a sounder 
union to take place. 

Schoeler, acting on the theory he holds concerning the cause 
of the condition, brushes weak chlorin water over the loss of sub- 
stance with a camel's-hair pencil, taking care at the same time to 
brush off all the loosened epithelium. His objct is to wipe away 
all small foreign bodies which may lie under the loosened epi- 
thelium preventing proper union. He follows this up with the 
use of atropin ointment and compresses of very weak chlorin 
water, and states that he has never seen a second relapse occur 
after this treatment. 

Blows on the Eye are liable to cause corneal bullae, the walls 
of which consist of Bowman's membrane and the epithelium. 
In some cases these bullae contain blood derived, no doubt, from 
the ruptured canal of Schlemm. Such bullae may also form after 
burns with lime, etc. 



THE CORNEA. i8i 

Another condition caused by blows on the eye is hemorrhagic 
discoloration of the true cornea, which presents a greenish or a 
reddish-brown color in the cornea. Hemorrhage in the anterior 
chamber is ahvays present at first. At first, too, the discoloration 
occupies the whole cornea, and after a time begins to clear up from 
the margin towards the center. The prognosis for vision is good, 
if the eye is otherwise sound, but the absorption of the coloring 
matter in the cornea is excessively slow, and as much as two or 
three years or more may elapse before the process is complete. 
Treacher Collins -^ has ascertained that the peculiar discoloration in 
these cases is due to the presence of hematoidin, which he thinks 
enters the cornea from the hemorrhage in the anterior chamber 
through Descemet's membrane by a process of diffusion. He did 
not find any red blood-corpuscles in the cornea. 

Burns of the Cornea. — Burns of the cornea from lime are not 
uncommon. The lime acts as a caustic, and destroys the cornea 
more or less deeply, with resulting more or less intense permanent 
cicatricial opacity. The lime, moreover, enters into chemical com- 
bination with the corneal tissues in the form of the albuminate of 
lime, which causes further opacity. 

Treatment. — As soon as possible after Ume has entered the eye 
it should be removed as thoroughly as possible by means of forceps 
and free washing out with water; or, better still, with saturated 
solution of sugar, which forms, with whatever loose lime may be 
present, an insoluble substance that may be readily removed. 

The removal of such albuminate of lime as remains fastened 
deeply in the cornea is difficult to effect, ^^^hen the irritation of 
the eye has subsided, the method proposed by Guillery -' may be 
employed. It consists in the application to the cornea, by means of 
an eye-bath, of a warm 2 per cent, solution of chlorid of am- 
monium, which dissolves out the lime. The bath is to be used 
several times a day for half an hour each time, and the strength 
of the solution may be gradually increased, according as the pa- 
tient can bear it, up to 20 per cent. 

Perforating Injuries of the Cornea. — In these cases the in- 
jury done is rarely to the cornea alone, and at the first inspection 
the attention of the surgeon is occupied less with the state of the 
cornea than with the question as to whether, and to what ex- 
tent, deeper parts of the eye (lens, vitreous humor, etc.) are in- 
volved. Another very important point which has often to be de- 
cided is whether or not the foreign body which has perforated 



i82 DISEASES OF THE EYE. 

the cornea is contained in the eye. But these matters belong to 
future chapters. 

A perforating wound of the cornea which does not involve 
any other part is serious in proportion to its extent, and to the 
probability of its being infected. Every perforating corneal 
wound is followed by loss of the aqueous humor, which flows away 
through it, and by consequent collapse of the anterior chamber; 
but in itself this is not a serious event. Short wounds close al- 
most at once (and through them indeed very little of the aqueous 
humor may flow off), the aqueous humor is rapidly restored, and 
no harm is done to the eye beyond a slight opacity, which, if in 
the pupillary area, may cause some defect of vision ; or, should the 
wound be situated more peripherally, and should the iris have lain 
against the cornea for a while, an anterior synechia may form. 

Long wounds, which may even occupy the cornea in its entire 
diameter without directly involving any other organ of the eye, 
are almost certain to be complicated by prolapse of the iris be- 
tween the lips of the wound, and when healing takes place the pro- 
lapsed portion becomes permanently incarcerated in the cicatrix. 
At the least this incarceration, if allowed to remain, causes irregu- 
larity in the curvature of the cornea, and consequent irregular 
astigmatism. But it may be the starting-point of a staphyloma 
of the cornea, it may become the cause of glaucomatous intra- 
ocular tension, or, if at any time a slight trauma with loss of sub- 
stance of its surface should occur, it may take on septic inflam- 
mation, which may spread rapidly to the deeper uveal structures, 
leading to panophthalmitis and loss of the eye. 

Treatment. — In small uncomplicated perforating wounds, with- 
out prolapse of iris, the aqueous humor being still wanting, at- 
ropin should be freely used if the wound be towards the center 
of the cornea, or eserin if it lie toward the periphery, with the 
object of preventing adhesions of the iris to the posterior aspect of 
the wound, and a bandage should be applied to the eye. 

In recent injuries of this kind, in which there is a prolapse of 
the iris, the latter, if not very large, may sometimes be reposed 
with a spatula or fine probe, aided by the action of atropin or 
eserin, according to the position of the wound. But in many in- 
stances this attempt will prove futile, while in those in which there 
is suspicion of septic infection, it is unwise to make it at all. In 
either circumstance the prolapsed portion of iris should be snipped 
off at its base. It is not enough to abscise a portion of the sum- 



THE CORNEA. 183 

mit of the prolapse. The prolapsed iris should be seized with an 
iris-forceps, drawn forward so as to loosen any adhesions be- 
tween it and the lips of the wound (or the adhesions may pre- 
viously be separated by a probe passed round the edges of the 
wound), and cut off close to the cornea. This affords the best 
chance of the iris receding into the anterior chamber without any 
of it adhering in the cornea. 

In cases which are not recent the adhesions between cornea 
and prolapsed iris will have become so firm that it will not be 
possible to separate them by any means, and the prolapse must be 
left to become cicatrized over, attention being directed to keep 
the tension of the eye low by means of eserin, punctures made 
in the prolapse, and ultimately an iridectomy, so as to produce a 
firm and flat cicatrix. 

Opacities of the Cornea. 

Nebula, Macula, Leukoma. — These terms are applied to opac- 
ities of varying degrees in the cornea, which are the result of 
some diseased process, or which are consequent upon an injury. 
The first term is used for very slight opacities, often discover- 
able only with oblique illumination. Macula indicates a more in- 
tense opacity, recognizable by daylight. Leukoma is a completely 
non-translucent and intensely white opacity, the result almost al- 
ways of an ulcer, which has destroyed most of the true corneal 
tissue at the affected place ; indeed, it is often the result of an ulcer 
which has eaten its way through the cornea. In these latter cases 
the iris may have become adherent in the corneal cicatrix, and then 
the term adherent leukoma is employed. 

Very often eyes with an old-standing nebulous condition of the 
cornea are myopic. It is probable that this myopia is produced 
by the habitual close approximation of objects to the eye, owing 
to the diminished acuteness of vision from the opacity of the 
cornea. 

Treatment. — Little or nothing can be done to reduce these opaci- 
ties. In slight and fresh cases massage with the yellow oxid of 
mercury ointment may render them less intense. 

In case of a nebulous cornea a stenopeic apparatus often im- 
proves the sight. This consists of a metal plate with a small 
central hole or slit, which is placed before the patient's eye in a 
spectacle-frame; and by this arrangement a large portion of the 



i84 DISEASES OF THE EYE. 

rays which pass through irregular parts of the cornea, and which 
merely confuse the sight, is cut off. Should the opacity be dense, 
and situated in the center of the cornea, portion of the margin 
having remained clear, an iridectomy will in some instances im- 
prove the sight. 

The Operation of Tattooing was first proposed by de Wecker, 
and is a valuable proceeding for improvement of the appearance 
of the eye in cases of leukoma. It is also an extremely useful 
method for improvement of the sight where the nebula occupies 
only part of the pupillary area of the cornea. In these cases 
much disturbance of sight is caused by the dispersion of the light 
which makes its way through the nebula; and when by tattooing 
the scar all light is prevented from getting through, brighter and 
distincter vision is enjoyed with the part of the cornea, opposite 
the pupil, which is absolutely clear. 

In the case of a leukoma either the whole surface of the leukoma 
may be tattooed or only part of it — e. g., its center, in order to 
represent a pupil. 

The material used is fine Indian ink rubbed into a very thin 
paste. The eye having been cocainized, the leukoma is spread 
over with this paste, and then covered with innumerable punctures 
by means of de Wecker's multiple tattooing-needle, each stab of 
which carries into the cicatricial tissue some of the black pig- 
ment. The coloration continues sufficiently intense for some 
months, but then often begins to get pale, owing, probably, to the 
pigment falling out of the punctures. A method of tattooing, by 
which the pigmentation lasts longer, is performed with de Weck- 
er's single-grooved needle. The pigment is placed in the groove 
of the instrument, which is then passed into the leukoma, a long 
canal being made in a plane parallel to its surface. On with- 
drawal of the needle the pigment remains behind. A large num- 
ber of such canals must be made in close proximity to each other 
until the desired intensity of color is obtained. Some operators 
remove the corneal epithelium over the part to be tattooed, in order 
to facilitate the entrance of the coloring matter into the true 
cornea. 

In cases where the whole cornea is leukomatous, and, conse- 
quently, where no restoration of sight can be obtained by means of 
an artificial pupil. Transplantation of a Portion of Clear Cornea 
from a rabbit's eye, or from a freshly enucleated human eye, has 
been repeatedly performed by ophthalmologists in various parts 



THE CORNEA. 185 

of the world. Very many of these operations have been per- 
fectly successful in a surgical sense — i e., in so far as the healing- 
in of the transplanted flap was concerned ; but, with a few excep- 
tions, they all ended in disappointment, in consequence of the flap 
not retaining its transparency. In the course of a week or two 
the transplanted portion invariably becomes as opaque as the leu- 
koma had been before. The mode of proceeding consisted in re- 
moving a portion of the leukoma with a trephine, and in then 
cutting a disc with the same instrument out of the clear cornea to 
be utilized, and inserting it into the opening in the leukoma. 

Various theories were formed to account for the occurrence 
of the opacity in the transplanted flap, but into these it is unneces- 
sary to enter here. Von Hippel ^ - came to the conclusion that 
the onset of the opacity was due to the entrance of the aqueous 
humor into the substance of the cornea, owing to the solution of 
continuity in its posterior epithelium ; Leber's experiments ^^ hav- 
ing shown that, unless this epithelial layer be intact, the trans- 
parency of the cornea cannot be maintained. Von Hippel, acting 
on this theory, applied a trephine to the leukoma as deep only as 
the posterior elastic lamina, and then dissected off the superficial 
layers contained within the ring, leaving the posterior elastic 
lamina and posterior epithelium. With the same trephine he then 
excised a disc of its entire thickness from a rabbit's cornea, and ap- 
plied it to the wound. Iodoform was dusted over this, and a band- 
age applied. Healing took place readily, and twenty months af- 
terwards the flap continued transparent, and vision = ^^. Von 
Hippel has had some other successful cases. 

Arcus Senilis. — -This is a change which is developed in the 
cornea without previous inflammation. It presents the appearance 
of a grayish line a little inside the margin of the cornea and all 
round it, most marked above and below, and never advancing 
farther towards its center. It is most common in elderly people, 
but is sometimes seen in youth, and even in childhood. No func- 
tional changes are caused by it, nor does it interfere with the heal- 
ing of a wound which may be made in that part of the cornea. 
Arcus senilis is caused by a hyaline degeneration of the corneal 
cells and fibrillse, and is not a sclerosis, as is stated by some 
authors. 



16 



1 86 



DISEASES OF THE EYE. 



References. 



*a*'Die Entstehung der Entzundung." Leipzig, 1891. 
^ " Ueber die Verwertbarkeit der Bindehaut in der praktischen und 
operativen Augenheilkunde." 

^ " Ophthalmiatrischen Beobachtungen," p. 107. 
^ " Von Graefe's Archiv," xii. 2. p. 250. 

* " Trans. Ophthal. Society, U. K.," xiii. p. 45. 
^ " Von Graefe's Archiv," xxxiv. 4. p. 250. 

* " Bericht der Ophthalmologischen Gesellschaft." Heidelberg, 1889. 
^ "Von Graefe's Archiv," xxxviii. i. p. 160; and xxxix. 2. 199. 

" " Archives d'Ophtahiiologie," xiii. 4. p. 193. 

* " Von Graefe's Archiv," xxv. 2. p. 285. See also Ibidem, xiii. i. 
pp. 114, 131. 

^^ " Bericht der Ophthalmologischen Gesellschaft." Heidelberg, 1898, 
p. 71. 

" " Zeitschrift fiir Augenheilkunde," II., pp. 235, 354. 

" " Von Graefe's Archiv," xlvi. i. p. 85. See also Ibidem, liii. p. 423, 
and " Zeitschrift fiir Augenheilkunde," viii. p. 340. 

" " Textbook of Ophthalmology." 

^* " Bericht der Ophthalmologischen Gesellschaft.' 
P- 53. 

^^ " Chirurgie Oculaire," p. 188. 

" " Centralbl. fiir Augenheilkunde," 1884, p. 378. 

'^'Ibidem, 1884, p. 378; 1885, p. 32. 

^^ " Trans. Ophthal. Society, U. K.," v. p. 200. 

^^ Ibidem, xii. p. 67. 

^° " Archives d'Ophtalmologie," 1885, p. 348. 

^^ " Klinisch. Monatsblatter fiir Augenheilkunde, 
" Bericht der Ophthalmologischen Gesellschaft." 
75, 78. 

'' " Ophthalmic Review," 1893, p. 317. 

''"British Medical Journal," 1880, p. 623. 

'* " Von Graefe's Archiv," xii, 3. p. 486. 

'^ " Centralblatt fiir Augenheilkunde," 1901, p. 161. 

'' " Trans. Ophthal. Society, U. K.," xv. p. 69. 

""Archiv fiir Augenheilkunde," xliv. p. 311. 

'* " Bericht der Ophthalmologischen Gesellschaft. 
p. 54- 

'^ " Von Graefe's Archiv," xix. 2. p. 87. 



Heidelberg, 1897, 



1894, p. 25. 
Heidelberg, 



See also 
1898, pp. 



Heidelberg, 1886, 



CHAPTER VII. 
DISEASES OF THE EYELIDS. 

Erythema^ erysipelas, phlegmonous inflammation, and abscess 
are all liable to attack the eyelids, but require no special observa- 
tions in this work. It should merely be stated that erysipelas of 
the eyelids may extend to the connective tissue of the orbit, and 
ultimately give rise to atrophy of the optic nerve. 

Eczema. — This is very often seen on the eyelids, most frequently 
in connection either with general eczema of the face or with phlyc- 
tenular ophthalmia. The lacrimation in phlyctenular ophthalmia 
increases the eczema, which then, by causing contraction of the 
skin of the lower lid, produces eversion of the inferior punctum 
lacrimale, and this, in its turn, causes increased lacrimation, and 
thus a vicious circle is set up. 

Atropin infiltration of the eyelid, from long use of solution of 
atropin in some persons, is often accompanied by a moist form of 
eczema of the lids and face. 

Treatment should consist in the daily removal of the scabs in 
such a way as to cause no bleeding of the surface underneath ; 
and for this purpose a warm solution of bicarbonate of potash is 
useful. The place should afterwards be well dried, and painted 
with a strong solution of nitrate of silver (gr. xx ad 5J), and a 
boric acid ointment (gr. xxx ad 5J), or the following, applied 
over this: Ol. Cadin, m xv ; Flor. Zinc, gr. xx; Lanolin, gij. — M. 
If the inferior lacrimal punctum be everted, the canaliculus should 
be slit up. 

Herpes Zoster Ophthalmicus is a herpetic eruption of the skin 
in the region supplied by the ophthalmic division of the fifth nerve 
of one side. 

Occasionally in the same case the second division of the fifth 
nerve may be affected, and, yet more rarely, the third division as 
well. One or two cases, too, have been published in which the 
zoster afifected each side of the face. 

But by far the most common case is the simple herpes zoster 
ophthalmicus, in which only the region supplied by the ophthalmic 

187 



1 88 DISEASES OF THE EYE. 

division of the fifth nerve is affected, and of this region it is usu- 
ally that portion alone which pertains to the supra-orbital and 
infratrochlear branches that is involved. The number of vesicles 
varies much ; there may be but one, or there may be several, or they 
may be so numerous as to become confluent. 

The appearance of the eruption is often preceded by a feeling 
of general discomfort, gastric disturbance, and high temperature. 
Yet more commonly is the eruption preceded by supra-orbital neu- 
ralgia, which is often of intense severity. This pain usually con- 
tinues, but may cease, after the eruption comes out, and sometimes 
it persists even for months after the eruption disappears. Pho- 
tophobia, due to the irritation of the fifth nerve, is not uncommon 
at the commencement of the aft'ection. Along with the appear- 
ance of the herpes the skin of the forehead becomes red and swol- 
len, and the appearances are often mistaken for erysipelas, but the 
strict limitation of the eruption by the middle line of the forehead 
is of itself sufficient to indicate the diagnosis. The upper lid is 
somewhat edematous and red, and droops a little over the eye, and 
this is much more marked when the skin of the eyelid itself is the 
seat of vesicles. 

The contents of the vesicles soon become purulent, the latter 
gradually dry up, and form crusts, under which are more or less 
deep ulcers, and as these penetrate the corium they, on healing, 
leave permanent scars, which at first are red, and later become of 
a glistening white. The entire eruptive process lasts about three 
weeks, and when it is completed the sensibility of the affected skin 
remains dull for a considerable time. Herpes zoster ophthalmicus 
is more common in adA^anced life than in youth, but it may appear 
at any age, even as young as the sixth month after birth. 

The disease is not associated with danger to the eye, unless 
keratitis comes on, or, what is much more rare, unless iritis, 
cyclitis, or chorioiditis appear. Hutchinson laid down the rule 
that the cornea does not become affected imless the eruption ap- 
pears on the region (the side of the nose) supplied by the naso- 
ciliary nerve, this being the nerve which gives the long root to 
the ciliary ganglion, as well as the long ciliary nerves. The rule 
holds good in most instances, but there are many exceptions to it. 
The conjunctiva is almost always slightly chemotic and injected, 
or there may be true conjunctivitis ; but vesicles are not often 
seen on it. 

There is considerable varietv in the forms of keratitis liable to 



THE EYELIDS. 189 

occur in herpes zoster ophthalmicus — viz., herpetic vesicles, phlyc- 
tenulse, bullae (any of which may go on to ulceration), superficial 
opacity without loss of substance, and parench3^matous opacity, 
either diffuse or punctate. The superficial opacities without loss 
of substance may disappear completely. Parenchymatous opacity 
either clears away altogether, or remains as a slight nebula ; while 
ulceration leaves, at the least, some opacity ; or, if it become septic, 
may seriously endanger the eye. Anesthesia, more or less well 
marked, attends the corneal affections, and remain* for a long time 
aftei they recover. 

Iritis is very uncommon in herpes zoster ophthalmicus, and is 
usually of a mild type, and iridocyclitis and chorioiditis are still 
more uncommon. They seldom occur unless keratitis is also 
present, and, like the keratitis, for the most part only when the 
cilionasal nerve is implicated. 

Herpes zoster ophthalmicus is due to an inflammatory process 
in the Gasserian ganglion, as Head and Campbell have shown, and 
in the opinion of these authors the skin eruption is caused by in- 
tense irritation of the ganglion cells. The lesion in the Gasserian 
ganglion is similar to that found in the posterior root ganglion in 
zoster of the trunk and limbs. Head and Campbell ^ believe the 
affection to be an acute specific disease — a view suggested by the 
facts that it occurs in the course of recognized infective diseases, 
that it occurs endemically and epidemically, and that it rarely 
occurs a second time. It is probable that the affection may also 
have a toxic origin, as when arsenic has been taken for a long 
time, and in carbonic oxid poisoning. 

Treatment. — It is doubtful whether treatment has any influ- 
ence in curing or in controlling the severity of an attack of herpes 
zoster ophthalmicus. Ouinin in full doses should be given, and 
a I per cent, cocain ointment made with equal parts of vaselin and 
lanolin should be smeared lightly over the affected part. Com- 
plications in the cornea or uveal tract are to be dealt with on the 
principles laid down in the chapters on diseases of those organs. 
The patient, unless the attack be a very mild one, should remain in 
bed. 

Primary Syphilitic Sores occur on the eyelids, usually near the 
margin of the upper or lower lid or at the inner or outer canthus. 
The first appearance is generally a small red swelling which the 
patient calls a " pimple," and which ulcerates and becomes char- 
acteristically indurated about its base. The margin of the ulcer 



190 DISEASES OF THE EYE. 

is clean-cut, and its floor somewhat excavated and covered with a 
scanty grayish secretion. Occasionally there is no ulcer present, 
but the entire lid is swollen, greatly indurated, purple, and shiny ; 
and then the diagnosis may be rendered difficult. The pre- 
auricular and submaxillary glands are almost always swollen ; and 
this is a valuable, although not altogether positive, diagnostic sign, 
as it is seen also in tubercular diseases of the conjunctiva. The 
occurrence of the sore is followed by the usual constitutional symp- 
toms of syphilis. Very rarely is there any permanent damage 
done to the eyelid. 

The most common modes of infection are by a kiss from a 
syphilitic mouth, or by a dirty finger. 

Treatment. — Locally, sublimed calomel by Kane's method, dust- 
ing with finely powdered iodid of mercury, or the black wash may 
be used ; while the usual general mercurial treatment is employed. 

Secondary Syphilis gives rise to ulcers on the margins of the 
lids, to loss of the eyelashes (madarosis), and to the secondary 
skin affections which attend it in other parts of the body. 

In Tertiary Syphilis ulcerating gummata of the lids sometimes 
are seen, accompanied by remains of previous iritis or keratitis. 

Vaccine Vesicles on the eyelids are produced by accidental 
inoculation at the intermarginal part of the lid ; or on the outer 
surface of the lid, if the skin be abraded by the finger-nail or other- 
wise. Sometimes the vesicle develops into a large ulcer with yel- 
lowish floor and hard and elevated margin. There is much pain, 
much swelling of the eyelid, and chemosis. 

Although distressing for a week or so while it lasts, the affec- 
tion is not a dangerous one, further than that a cicatrix in the skin 
is left behind, and the eyelashes at the affected part are lost. 

Treatment. — A warm chlorate of potash lotion (gr. v ad ,^j.) is 
the best application. 

Rodent Ulcer (Jacob's Ulcer). — This disease commences a^ 
a small pimple or wart on the skin near the inner canthus, or over 
the lacrimal bone, as a rule ; but it may also originate in any other 
part of the face. The scab or covering of the wart is easily re- 
moved, and underneath is found a shallow ulcer with a well- 
defined, indurated margin; the skin surrounding the diseased 
place being healthy, and continuing so to the end of the chapter. 
The progress of the disease is extremely slow, extending over a 
great number of years, and in the early stages the ulcer may even 
seem to heal for a time, but always breaks out again. In mild 



THE EYELIDS. 191 

cases the ulceration may remain superficial ; but more usually it 
strikes deep, in the course of time eating away every tissue, even 
the bones of the face and the eyeball. The latter is often spared 
until after the orbital bones have gone. 

The disease is an epithelial cancer of a non-malignant or purely 
local kind. There is no tendency to infiltration of the lymphatics. 
It is rarely seen in persons under forty years of age. 

Treatment. — Extirpation of the diseased part affords the best 
chance of relief for the patient. Recurrence of the growth is the 
rule, but this should not deter from operative measures, nor even 
from the renewal of them, as they afford much comfort to the pa- 
tient and prolong his life. Even in advanced stages operation is 
frequently called for. The application of chlorid of zinc, or of the 
actual cautery, should be employed, after the disease has been as 
thoroughly removed with the knife as is possible. 

Bergeon's Treatment. — This consists in the internal administra- 
tion of 5 grains of chlorate of potash three times a day, with the 
local application of a saturated solution of chlorate of potash to the 
ulcer, and by aid of it remarkably good cures, even though not al- 
ways permanent ones, can be effected. It is well, in many cases, 
to scrape the ulcer before applying the solution. The process must 
be repeated daily, or at least every second or third day. It is cer- 
tainly painful, but not unbearably so. Sometimes a green slough 
is produced, and when this is the case there is generally some sur- 
rounding inflammation, which should be allowed to subside before 
going on with the treatment. As the healing process does not be- 
gin until the diseased tissue has been removed, the progress may 
seem slow for the first week or fortnight ; but no case resists the 
treatment altogether if it be persevered with. While the chlorate 
of potash destroys the disease, it does not act injuriously on the 
delicate epithelium, which begins to grow in from the margin as 
healing sets in, and it should therefore be continued until the whole 
surface has healed. Another fortunate peculiarity is that it has 
no effect on the normal conjunctiva, and may be used without 
fear if this membrane be involved in the disease. 

Marginal Blepharitis ( /SXecpapov, eyelid), or Ophthalmia 
Tarsi, is nothing else than eczema of the margin of the eyelid. It 
is found either as Blepharitis Ulcerosa (Eczema Pustulosa), or 
as Blepharitis Squamosa (Eczema Squamosa). In the former 
small pustules form at the roots of the eyelashes, and these, having 
lost their covering, become ulcers, which scab over. The whole 



192 DISEASES OF THE EYE. 

margin of the lid may then be covered with one large scab, in 
which the eyelashes are matted, and under which the lid will be 
found swollen, red, and moist, with many fninute ulcers and pus- 
tules. Many eyelashes come away with the scab, and others are 
found loose and ready to fall out. 

The disease is chronic, and is most commonly seen in strumous 
children. It is frequently accompanied by phlyctenular oph- 
thalmia, or by simple conjunctivitis, which may have been its cause, 
or which promotes it by keeping the margin of the lid constantly 
wet. 

If neglected, ulcerous blepharitis is liable to produce trichiasis 
by giving a false direction to the bulbs of the cilia. 

Many ophthalmologists hold that blepharitis is often caused by 
ametropia, especially by hypermetropia or hypermetropic astig- 
matism., in consequence of the incessant efforts of accommodation. 
I cannot go so far ; but it may be that, if blepharitis be once set up, 
such anomalies of refraction may help to keep it going. 

The Treatment of Ulcerous Blepharitis consists, in the first place, 
in the careful removal of the scabs without causing any bleeding 
of the delicate surface underneath. Such bleeding indicates that 
the newly formed epithelium has been torn away, and it is impor- 
tant, therefore, to soften the scabs by soaking the eyelid with olive 
oil, or with a solution of bicarbonate of potash, before removing 
them. Any pustules found under the scab should be punctured, 
and all loose eyelashes taken away, and the ulcers touched with a 
fine point of solid mitigated lapis. The surface should then be 
well dried by pressure, not by rubbing, with a soft cloth, and the 
following ointment (Hebra) applied: R. Ol. Rusci (or Ol. Juni- 
peri) 5ss, Hydrarg. Ammon. Chlor. gr. iv, Vaselin alb.. Lanolin 
aa 5ij. This ointment is to be continued until healing is thor- 
oughly established.- In many mild cases a boric acid ointment (gr. 
V ad 5j of vaselin or of lanolin) will be found efficacious instead 
of the above, and a white precipitate ointment of from i to 2 per 
cent, acts well. A creolin ointment suits many cases — viz., Creo- 
lin, I to 5 min. ; Aq., 5ij ; Lanolin, 5vj. 

Or, again, after the scabs and loose eyelashes have been removed 
as above, the margins of the eyelids may be freely bathed with a 
wash of ten to twenty minims of creolin to eight ounces of water, 
and after this the creolin ointment may be applied. I have found 
this method very successful. But in all cases, whatever the lotion 
or ointment ordered may be, the ulcers should be touched with 



THE EYELIDS. 193 

mitigated lapis, as above recommended, and all loose eyelashes re- 
moved. 

All complications with conjunctival affections or lacrimal ob- 
struction must be attended to, and the patient's general system 
carefully improved. Any error in refraction should be suitably 
corrected. 

Squamous Blepharitis comes on after the ulcerous form has 
passed away; or it is found as a primary affection, especially in 
chlorotic women. The margin of the lid is somewhat swollen and 
red, and covered with loose epidermic scales. It is an extremely 
chronic affection. 

The Treatment of Squamous Blepharitis is also an ointment of 
Hebra's : 

I^ Emplast. Diachylon Co.,* 3 ij ; Ol. Olivar, q. s. ; 

or the Boric Acid ointment may be used. 

Chlorosis, if present, is to have suitable remedies. 

Phtheiriasis {^cp^eip, a louse) Ciliorum. — The pediculus pubis 
occurs on the eyelashes. It gives rise to excessive itching and 
burning sensations, and the consequent rubbing produces excoria- 
tions of the margin of the lid. The lice occupy chiefly the roots 
of the eyelashes, while the shafts of the cilia are covered with their 
brown egg-capsules, and this gives to the cilia the peculiar ap- 
pearance of being covered with dark brown powder, which enables 
the diagnosis to be easily made. The fully developed parasites, as 
well as the eggs, may be more readily seen by aid of a strong con- 
vex glass. 

Treatment. — With a cilium forceps the pediculi may be to a 
great extent, or completely, removed, as well as some of the eggs 
from the cilia. This proceeding repeated daily, along with the 
application of mercurial ointment, or of a weak red precipitate 
ointment, to the margin of the eyelids morning and evening, will 
soon effect a cure. 

Hordeolum {hordeiim, a grain of barley) or Stye, is a 
circumscribed purulent inflammation situated at the follicle of an 
eyelash. It commences as a hard swelling, with more or less tume- 
faction and edema of the general surface of the lid, and often with 
some chem.osis, especially if it be situated at the outer canthus. In 

* Emplast. Diachylon Co. is made as follows : Emplast. Litharg. B. P., 
12 parts; Corntlour, i 1-2 part; Ammoniac, Galbanum, Turpentine, of each 
I part. 



194 DISEASES OF THE EYE. 

its early stages there is much pain associated with it. It gradually 
suppurates, and may then be punctured or allowed to open of itself. 

Styes frequently come in rapid succession one after the other, 
and then, probably, a constitutional disturbance exists as the cause. 
In the earliest stage cold applications may be successful in putting 
back a stye, but, later on, warm stupes will hasten the suppuration 
and relieve the pain. Habitual constipation is a common source 
of hordeolum, and should be met by the occasional use of cascara 
sagrada, aperient mineral water, or other mild laxative. Sulphid 
of calcium, i-io gr. every hour, or 1-2 gr. twice a day, for an adult, 
has been recommended ( D. Webster) as a specific in these cases. 

Chalazion (j^Aa'<?«'^ hail), Meibomian Cyst, or Tarsal 
Tumor, is probably a granuloma in connection with a Meibomian 
gland, and not a mere retention cyst. Micro-organisms have 
been found by some observers in these tumors, but what relation 
exists between them and the tumors is a matter upon which 
opinions dififer. Chalazion has its origin in a chronic inflammatory 
process in the connective tissue surrounding the gland, which usu- 
ally passes ofT without having attracted the attention of the patient. 
The tumors vary in size from that of a hemp-seed to that of a hazel- 
nut, causing a marked and very hard swelling in the lid. They 
occasionally open spontaneously on the conjunctival surface, giv- 
ing exit to contents which are usually viscid or grumous, but some- 
times purulent. 

Treatment. — No application can bring about absorption of these 
tumors. The lid should be everted, the tumor opened by a single 
incision from the conjunctival surface, and its contents thoroughly 
evacuated by aid of a scoop or small sharp spoon. Difficulty is 
sometimes experienced in finding the point in the conjunctiva cor- 
responding to the tumor, but it is usually indicated by a dusky or 
grayish discoloration. Immediately after the evacuation, bleed- 
ing into the sac often takes place, and causes the tumor to remain 
for a day or two as large as before — a fact of which the patient 
should be warned. The operation may occasionally require to be 
repeated tv/o or three times. The interior of the sac should not 
be touched, with nitrate of silver ; and the incision and evacuation 
should never be made through the skin, because more or less dis- 
figurement from the scar would result. 

More than one chalazion is often present at a time, and some 
people become liable to them periodically during a number of years. 

Milium (milium, a millet seed) presents the appearance of a 



THE EYELIDS. 195 

perfectly white tumor, not much larger than the head of a pin, in 
the skin of the eyelid. It is a retention tumor of a sebaceous gland, 
and can readily be removed by puncture and evacuation. 

Molluscum, or Molluscum Contagiosum.— This is a v^hite 
tumor in the skin of the eyelid, which may attain the size of a 
pea. At its summit is a depression, which leads to an opening 
into the tumor, through which the contents can be pressed out. It 
is probably a diseased condition of a sebaceous gland, and con- 
tains altered epithelial cells and peculiar bodies, termed mol- 
luscum corpuscles, which are of a fatty nature. Many such 
tumors may form in the lids at the same time. 

It is held by some observers that this affection is contagious, 
although in what way is not clear, inasmuch as experimental rub- 
bing of the contents of a molluscum into the skin has not given 
rise to the tumors. 

Treatment. — Each separate tumor must be evacuated by simple 
pressure, or after it has been opened up with a knife or scissors. 

Telangiectic Tumors, or Nevi, of the eyelids occur con- 
genitally. 

Treatment. — Small tumors of this kind may be destroyed by 
touching with nitrate of silver or hydrochloric acid, or by perform- 
ing vaccination on them. Large tumors may be ligatured or 
treated with the galvano-cautery, and electrolysis is a very 
effectual method in many cases. 

Xanthelasma {^ar^Oby yellow; i'Xaa}j.o^^ a layer) is the term 
applied to yellowish plaques raised slightly over the surface of 
the skin, with very defined miargins. The patches are generally 
bilateral and symmetrical, and are most frequently situated in the 
neighborhood of the inner canthus. The shape of these plaques 
is extremely irregular, and they may attain the size of a shilling 
or larger. The appearance is caused by hypertrophy of the seba- 
ceous glands, with retention of their contents, and fatty degenra- 
tion of the subcutaneous connective tissue. 

Treatment can only consist in removal by careful dissection, and 
this is hardly to be reconimended except in extreme cases. 

Palpebral Chromidrosis (xp(^M(x, color; i'dpojai?, sweating) . — 
The phenomenon of an exudation of pigment upon the eyelids, of 
which about fifty cases have been recorded, has given rise to 
much discussion. The opinion held by many is that these cases 
are always the result either of deception in hysterical individuals, 
or of accidental circumstances, such as the exposure of a patient 



196 



DISEASES OF THE EYE. 



with seborrhoea palpebrarum to an atmosphere loaded with coal- 
dust or pigmentary matter, in some manufacturing district. Of 
the fact that the appearance has occurred under both of these con- 
ditions there can be no doubt. There would seem also to be evi- 
dence that some genuine cases of color-sweating on the eyelids 




Fig. 60. 



have been observed ; but they must be extremely rare. The dis- 
coloration is blue or black, and occurs in the form of fine powder 
upon the skin of one or both eyelids of both eyes. It can be wiped 
ofif, and is said to begin to reappear after a short interval. The 
subjects of it have been chiefly young girls, but it has also been 
seen in women of advanced years, and even in middle-aged men. 



THE EYELIDS. 197 

The Treatment in a genuine case may consist in the application 
of a lotion of liq. plumbi and glycerin ; and, internally, iron, 
quinin, and arsenic, along with the regulation of the general sys- 
tem, particularly in respect of any uterine derangement. 

Epithelioma, Sarcoma, Adenoma, and Lupus are all seen in 
the eyelids, but require no special description here. 

The condition known as Solid Edema, or Elephantiasis 
Lymphangiodes of the Eyelids, is well represented in the ac- 
companying picture (Fig. 60 '^) of a case under the care of Sir A. 
Critchett. It is a chronic tumefaction of the eyelids, most marked 
in the lower lids. The skin covering the swelling is smooth and 
pale, and suggests to the eye the skin of an edematous lid ; but on 
palpation the swelling is found to be much more resistant than 
simple edema. There is, almost invariably, a history of recurring 
attacks of facial erysipelas. These give rise to a permanent altera- 
tion of the lymph channels, and, each attack leaving its trace, an 
ever-increasing hypertrophy of the tissues of the eyelids takes 
place. 

Treatment. — Operative measures have been adopted in many 
instances with satisfactory results, both cosmetically and as regards 
the functions of the eyelids ; but, unfortunately, in those cases 
which have remained under observation sufficiently long, the 
former condition gradually returned, as in Sir A. Critchett's case. 
Multiple punctures, collodion, pressure, etc., and many internal 
remedies have been tried in vain. 

Clonic Cramp of the Orbicularis Muscle, or of a portion of 
it, is often seen, and is popularly known by the name of '' life " in 
the eyelid. It is frequently due to overuse of the eyes for near 
work, especially by artificial light, or if there be defective ampli- 
tude of accommodation. 

Treatment should consist in the regulation of the use of the 
eyes for near work, and the correction by glasses of any defect in 
the accommodation. 

Blepharospasm, or Tonic Cramp of the Orbicularis Muscle, 
is commonly the result of irritation of the ophthalmic division of 
the fifth nerve by reflex action, as in phlyctenular ophthalmia and 
some other corneal and conjunctival affections ; or from foreign 
bodies on the conjunctiva or cornea, etc. ; or it may continue for 
some time after the relief of any such irritation. It occurs, also, 

* Taken by permission of the Council from " Trans. Ophth. Soc, 
U. K.," vol. xix. 



198 DISEASES OF THE EYE. 

independently of such causes, and is then difficult to account for, 
unless as a hysterical symptom. Yet even in these obscure cases 
the spasm is probably often a reflex from the fifth nerve, and it 
will be found that pressure upon the supra-orbital nerve at the 
supra-orbital notch may arrest the spasm ; or, if not there, then 
pressure on the infra-orbital, temporal, malar, or inferior alveolar 
branch may have the desired effect. 

Treatment. — If the cause of the reflex cannot be ascertained, or 
if it has passed away, and if the cramp be still very distressing, 
stretching or resection of the branches of the fifth nerve, from 
which the reflex proceeds, may be tried. 

Ptosis {Tttc^ffi?, a fall), or Blepharoptosis, is an inability to 
raise the upper lid, which then hangs down over the eyeball. It 
is either congenital or acquired ; and in the latter case is most 
usually the result of paralysis of the branch of the third nerve sup- 
plying the levator. 

Persons affected with ptosis involuntarily endeavor to raise the 
eyelid by an overaction of the frontalis muscle. The drooping lid 
and elevated eyebrow give a peculiar and characteristic appearance. 

The Causes of Paralytic Ptosis are similar to those of paralysis 
of other branches of the third pair, more especially exposure to 
cold draughts of air while the body is heated, and syphilis or rheu- 
matism affecting the branch to the levator palpebrse in its course. 
It may also be due to cerebral disease (see chap. xvii.). The 
branch to the levator may be paralyzed alone, or in conjunction 
with other third-nerve branches, and the loss of power may be par- 
tial or complete. 

The Treatment of a recent case of ordinary paralytic ptosis de- 
pends upon its cause. If this be syphiHs, then a course of mer- 
curial inunctions or of iodid of potassium ; if rheumatism, salicy- 
late of soda or iodid of potassium — with, in either case, protection 
of the eye and side of the head by means of a warm bandage. 
Cases in which these remedies have failed, and which have become 
chronic, often demand operative treatment. Attempts have been 
made, with success in some cases, to obviate the inconvenience of 
ptosis by giving support to the lid by wire splints worn like an eye- 
glass or attached to the upper edge of spectacle-frames. 

Ptosis due to a cerebral lesion rarely comes within the scope of 
treatment.* 

* The value of ptosis as a localizing symptom in cerebral disease will 
be treated of in chap, xvii 



THE EYELIDS. 



199 



Operative treatment is indicated in cases of paralytic ptosis — 
where other measures have produced no result — in ptosis adiposa, 




Fig. 61. 







Fig. 62. 





Fig. 61 shows intended track of wire. 

Fig. 62. — Wire loop d, with needle ends passed upwards in thickness of 

tarsus, and turned out at b b,, to be taken subcutaneously to e e by 

ptosis needles (c c) passed from above eyebrow. 
Fig. 63 shows wire at e in eye of ptosis needle above eyebrow; d, point of 

needle threaded with wire projecting at middle of lid before being 

drawn up to e. 
Fig. 64. — Completed except sinking wire knot permanently. 

and in congenital cases. A very common proceeding consists in 
the excision of a sufficiently large oval piece of integument, its 



200 DISEASES OF THE EYE. 

long axis lying in the length of the lid, with the subcutaneous con- 
nective tissue and fat, and, in paralytic cases, a small portion of 
the orbicular muscle. The fold of integument to be abscised is 
seized by two pairs of forceps — one of them held by an assistant — 
at the inner and outer ends of the lid, and by this means the neces- 
sary size of the fold is estimated. The abscission of the fold is per- 
formed with a pair of scissors, the margin of the wound lying close 
to the points of the forceps. The subcutaneous tissue, etc., is then 
removed, and the edges of the wound drawn together by a few 
points of suture. 

Mules' Operation.^ — A Knapp's clamp is applied to the lid to 
be operated on. The edge of the tarsus is then grooved one-third 
of an inch in length and deeply enough to permit of perfect and 
easy healing over the wire bend (Fig. 62, d) ; the grooving should 
be behind the bulbs of the lashes, to prevent their being directed 
abnormally inwards. After grooving, the Desmarres ring may be 
removed, and the lid drawn tense with the lid-forceps. Next, at 
each end of the groove (Fig. 62, a a), one sewing needle with 
wire is passed upward half the width of the lid in the center of the 
tarsus, so as to give a strong bite for the wire bend, then thrust 
forwards and outwards through the tarsus (at b b) and skin, the 
wire being drawn through the small incision made there. The 
ptosis needles (c c) are now pushed deeply from above the brow, 
a quarter of an inch apart, into the tiny apertures made for them 
by a thrust of the sclerotomy knife, then underneath the eyebrow 
downwards to the incision (b b) in the skin of the lid, through 
which the wire has already passed, and their points are also turned 
out there (Fig. 63, d). The wire is cut from the sewing-needles, 
threaded through the eyes in the points of the ptosis needles, with- 
drawn through the small apertures in the skin of the lid, and 
brought out above the brow at the points of entry of the ptosis 
needles (e) ; the wire bend is then drawn firmly into the grooved 
edge of the lid to allow of immediate healing, a little iodoform 
dusted on the groove and small incisions, the wire ends shortened, 
the apertures dressed with collodion and iodoform, and a pad 
and bandage applied. After all swelling of the lid has passed, 
the permanent effect may be secured by tying the wire after careful 
adjustmient of the lid, and sinking it into a small skin incision 
made for the purpose (Fig. 64). 

Pagenstecher's Method is as follows : Its object is to enable 
the patient to derive more benefit from the effort of his frontalis 



THE EYELIDS. 



20 1 



muscle, which he is constantly making with so little result, by 
transferring its action more directly to the eyelid. A needle carry- 
ing a thick ligature is entered under the skin of the forehead about 
half an inch above the center of the eyebrow, and passed subcu- 
taneously as far as the margin of the eyelid at its middle point. 
The suture is closed, not very tightly at first, but each day some- 
what more tightly, until it has cut its way through the skin. As 
the result of this a cicatrix is formed in the course of the ligature 




Fig. 65. 



which gives the frontalis much more power over the eyelid. I 
have tried this method, but I have not been satisfied with it. 

Birnbacher's Operation is an improvement on former attempts 
to connect the tarsus with the frontalis by cicatrices. An in- 
cision, with its convexity upwards, is made in the skin correspond- 
ing to the upper edge of the tarsus. Three sutures with a needle 
at each end are passed through the upper border of the tarsus, so 
as to form three loops, one central and two lateral ; the two needles 
of the central loops are passed vertically upwards under the skin, 
and are brought out quite close to one another in the eyebrow. The 
lateral loops are treated in the same way, but are made to diverge 
on each side from the central one, instead of being parallel. The 
17 



202 



DISEASES OF THE EYE. 



ends of the threads are tied over a small roll of lint, and tightened 
until the edges of the lids just touch when the patient closes the 
eye. They may be left in from twenty to twenty-five days.^ 

Panas' Method.^ — The object of this operation is to bring about 
a union between the lid and the frontalis muscle by forming a flap 
in the former, which is fastened to the skin of the forehead and to 
the surface of the muscle. 

Before the operation commences, and while it is in progress, an 
assistant applies his hand firmly to the patient's forehead, in such 
a way as to prevent shifting of the skin of the eyelid over the un- 




FiG. 66. 



derlying tissues, which would interfere with the exactitude of the 
proceeding. 

A horn lid-spatula is inserted under the lid. Fig. 65 explains 
how the eyelid flap is formed. The horizontal incision along the 
top of the flap has a slight convexity upwards, is not quite an inch 
long, lies over the orbital margin, and goes through all the tissues 
down to the periosteum. Another incision, parallel to this one, 
rather more than an inch long, is made along the upper border of 
the eyebrow and as deep as the periosteum. The flap of skin and 
muscle is now dissected from the tarsus down to its ciliary border, 
but the suspensory ligament of the lid must not be interfered with. 
The bridge of tissue between the two horizontal incisions is now 
to be undermined without injury to the periosteum or suspensory 
ligament. The flap is then drawn up under the bridge by means 



THE EYELIDS. 



203 



of the sutures (a a') and secured to the upper edge of the upper 
incision. Inasmuch as the traction exercised by the flap when so 
fixed tends to produce ectropion of the Ud, two lateral sutures 
{b b') are applied deeply through the suspensory ligament and 
conjunctiva to the exclusion of the skin, and are attached, like the 
other sutures, to the upper lip of the upper incision, thus counter- 
acting the tendency to ectropion. Fig. 66 shows the effect of the 
operation. 

Fuchs has published ^ some cases of bilateral ptosis in elderly 
people, which were due, in his opinion, to primary atrophy of the 




Fig. 67. Fig, 68. 

I, levator palpebrse; 0, orbicularis. 



levator palpebrae muscles. The eyelids were elongated and 
thinned, so that the eyeball showed plainly through them. The 
loss of power had in each case been very slowly increasing for 
many years. 

Congenital ptosis is generally present in both eyes. It is due in 
some cases to an imperfect development of the levator palpebr^, 
and in others to an abnormal insertion of this muscle, its tendon 
being attached to the tarsus too far back. Either Birnbacher's or 
Panas' operation may be employed, and Everbusch has proposed 
the following proceeding more particularly for congenital ptosis : 



204 



DISEASES OF THE EYE. 



Evcrbusch's Operation for Congenital Ptosis'^ (Figs. 67 and 
68). — The object of the operation is to increase the power of the 
levator by advancing its insertion, or rather by doubUng it down 
over the tarsus, to which it forms fresh adhesions. Snellen's lid- 
clamp is applied, the plate being passed well up into the fornix; 
and, before the ring is screwed down, the skin of the lid is drawn 
down, so that its prolongation just under the eyebrow may be 
forced into the instrument. The skin and the underlying orbi- 
cularis are now divided in the entire width of the Hd, parallel to its 
free margin, and at a distance half-way between this margin and 
the eyebrow. The skin and the subjacent muscle are then sepa- 




rated up, both upwards and downwards, for 4 mm. in each direc- 
tion, so that the insertion of the levator may be well exposed. A 
suture with a small curved needle at either end is then introduced 
by means of one of these needles horizontally into the tendon at its 
insertion, and near the center of the latter, in such a way that 
about 2 1-2 mm. of the tendon may be included in the suture. 
Each needle is now passed vertically downwards between the tarsus 
and orbicularis, and brought out at the free margin of the lid at a 
distance from each other of about 21-2 mm. Two more such 
double sutures, one in the temporal, the other in the nasal, third of 
the tendon, are similarly applied. The margins of the horizontal 
skin and muscle wound are now drawn together, and then the three 



THE EYELIDS. 205 

sutures are closed tightly. It is desirable to slip glass beads over 
the ends of the sutures before tying them, to prevent cutting into 
the margin of the lid. Both eyes are bandaged, and the sutures 
left in for a week or more. 

Hugo Wolff's Operations for Congenital Ptosis by advance- 
ment of the levator palpebrse superioris : 

Method I. (Fig. 69). — An incision of about 2 cm. in length 
is made through the skin of the upper lid in a position corre- 
sponding to the upper border of the tarsus, and the lips of the 
wound are each dissected up for a distance of 3 mm. By this 
means the orbicularis is laid bare. In the center of the wound, 
and at the upper margin of the tarsus, a fold of the orbicularis 
of about I cm. in width, with the subjacent levator tendon, is 
seized in the forceps. This fold is isolated in a vertical direction 
by a few strokes with the scissors, and is undermined. Two stra- 
bismus hooks are then passed under it, and placed so that one of 
them lies close to the insertion of the levator tendon in the tarsus.* 
The amount by which it is desired to raise the lid is measured off 
on the tendon from its insertion, and Schweigger's strabometer 
is convenient for this purpose. (If, for example, the palpebral 
opening in the normal eye is 10 mm., while that in the eye to be 
operated on is 3 mm., it will be required to raise the drooping eye- 
lid 7 mm.) At the point found by this measurement two sutures, 
each with two needles, are applied in the muscle, and the latter is 
divided immediately below the ligatures. The four needles are 
then passed through the stump of the tendon at its insertion, and 
through the portion of orbicularis which covers it ; the sutures 
are tied, and cut off short, and the skin wound is then closed by a 
few sutures. 

Method II. — From the conjunctival surface. The eyelid is 
everted in the usual manner; the upper margin of the tarsus is 
then seized in the double-legged fixation forceps, and the lid is 
rolled over again, and by this means the field of operation is 
brought into view. To prevent bleeding a lid-clamp is now ap- 
plied. On the right margin (as looked at by the operator) of 
the field of operation a fold of conjunctiva is raised and divided 
vertically, and the conjunctiva is undermined upwards, down- 
wards, and to the left, and divided by a horizontal incision about 
2 cm. in length. The conjunctival flaps are turned upwards and 

* H. Wolff states that he finds the insertion of this tendon is 5 mm. 
below the upper margin of the tarsus. 



2o6 DISEASES OF THE EYE. 

downwards, and then the levator, with Miiller's muscle lying on it, 
is exposed to view. With the forceps a portion in the center of 
the muscle, about i cm. wide, is seized and isolated from its 
bed by a few vertical strokes with the closed scissors. Two 
strabismus hooks are inserted under the isolated portion of muscle, 
one of them lying close to the convex margin of the tarsus, and 
then the clamp and fixation forceps are removed. In place of the 
strabismus hooks Wolff's spatula, with millimeter scale engraved 
on it, can be used. At the desired distance from the upper mar- 
gin of the tarsus (which must precisely represent the difference 
between the palpebral opening in the sound eye and that in the 
faulty eye) two catgut sutures, with two needles each, are tied 
in the muscle, so that each knot will include more than half of the 
isolated portion of the muscle. The muscle is then divided close 
below the point of ligature ; the needles are passed through the 
stump close to the upper margin of the tarsus, which is also in- 
cluded ; the sutures are closed, and cut off short. The conjuncti- 
val wound is then also closed. 

A remarkable condition is Congenital Ptosis, with Associated 
Movements of the Affected Eyelid, during the action of certain 
muscles. There are only about thirty cases of this on record. It 
is most commonly the left lid which is affected, and the paralysis 
may be congenital or acquired. Three conditions have been ob- 
served — viz., (i) elevation of the drooping lid when the eye is 
adducted, (2) when the eye is abducted, or (3) when the mouth 
is open. A synchronous contraction of the pupil has been noticed 
in some cases, while in some the elevation of the lid occurs also 
with a lateral motion of the jaw, and with deglutition. Gowers' 
explanation is that in these cases the levator is not wholly sup- 
plied by the third nerve, but partly also by nerve fibers, which 
take their origin in the nucleus of the fifth pair, and which also 
supply the external pterygoid and digastric muscles. But this 
theory does not hold good in all cases, for Bull ^ describes a case 
in which the lid was raised when the head was bent back, thus 
stretching the digastric. He regards these as associated or re- 
flex movements. In some instances the lid can be raised volun- 
tarily on closing the other eye. Needless to say, no remedy can 
be applied for relief of this condition. 

The term ptosis is also given, although not very correctly, to 
cases in which increased weight of the lid causes it to droop, as in 
conjunctival affections, or where a tumor has formed in the eye- 



THE EYELIDS. 20; 

lid, or where there is a hyperdevelopment of the subcutaneous 
fat. 

Lagophthalmos {Xayoo<^, a hare, as it was supposed that this 
animal sleeps with its eyes open; bcpBaXjuo?), or inability to close 
the eyelids, is most commonly due to paralysis of the portio dura, 
and is then associated with the other symptoms of the latter affec- 
tion. On an effort to close the lids being made, the eyeball is 
rotated upwards under the upper lid, owing to the associated 
action of the superior rectus ; and in sleep this upward rotation 
also occurs — a fact which explains, to a great extent, the immunity 
of the cornea from ulceration in many of these cases. Lagoph- 
thalmos may also be due to orbital tumors pushing the eyeball for- 
wards, to exophthalmic goitre, to staphyloma, or to intra-ocular 
growths distending the walls of the eyeball — in all of which con- 
ditions the eyelids are often mechanically prevented from closing 
over the eyeball, or can be closed only by a strong effort of the 
will. The danger to the eye depends upon the tendency to ulcera- 
tion of the cornea from its dryness, caused by exposure to the air, 
and from foreign substances not being removed from it by nictita- 
tion. 

In cases of non-paralytic lagophthalmos protection of the cornea 
by keeping the eyelids closed with a bandage, or by inserting a few 
epidermic sutures in the margins of the eyelids, to draw them 
together, should be our first care. Tarsorrhaphy may be employed 
in those cases where circumstances indicate that it would be useful 
— e. g., in some cases of exophthalmic goitre, or of staphylomatous 
eyeball. 

In paralytic cases, the primary cause of the paralysis (syphilis, 
rheumatism, etc.) must be treated so long as there is a prospect 
of restoring power to the muscle. Locally, galvanism and hy- 
podermic injections of strychnia may be employed. During cure 
the cornea should be protected as above. In incurable cases the 
opening of the eyelids must be reduced considerably in size by an 
extensive tarsorrhaphy, or by the method proposed by Pfliiger. 

The Operation of Tarsorrhaphy consists in uniting the margins 
of the upper and lower lids in the neighborhood of the external 
commissure, so as to reduce the size of the opening of the eyelids. 
The commissure should be caught between the finger and thumb, 
and the edges of the lids approximated, so as to enable the oper- 
ator to form an estimate of the required extent of the operation. 
A horn spatula is then passed behind the commissure, and the 



2o8 DISEASES OF THE EYE. 

necessary length of the margin of each Hd, inckiding the bulbs of 
the cilia, abscised with a sharp knife. The raw margins are then 
brought together with sutures. 

Pflugers Method ^ consists in passing one, two, or even three 
double sutures subcutaneously around the eyelids, about 5 mm. 
from their margins. The ends are drawn together, so that the 
eye is concealed by the pouch thus formed, and tied. From time 
to time the sutures are tightened, until finally they cut through, and 
by this means a subcutaneous ring-cicatrix is produced. Should 
the first ring-cicatrix not sufficiently close the eyelids, the opera- 
tion can be repeated even more than once again. The method is 
tedious and painful. 

Symblepharon {ovv^ together ; fSXecpapor, the eyelid) is an ad- 
herence, partial or complete, of the eyelid to the eyeball. It is 
usually the result of burns of the conjunctiva by fire, acids, or 





Fig. 70. Fig. 71.* 

lime. The shortening of the conjunctival sac, which is seen as 
the result of pemphigus or of granular ophthalmia, and which 
I have above described under the heading of Xerophthalmos, is not 
properly called symblepharon. If the symblepharon interfere 
seriously with the motions of the eyeball, or if it cause defect of 
vision by obscuring the cornea, it becomes desirable to relieve it 
by operation. Should it consist of a simple ba;nd stretching from 
lid to eyeball, it may be severed by ligature, and if the band be 
broad, two ligatures may be employed, one for either half. A 
symblepharon which occupies a considerable surface cannot be 
got rid of in this way ; and for such cases a transplantation pro- 
cedure like that of Teale ^^ or of Knapp '^ may be employed, the 
great difficulty in dealing with these cases being the tendency there 

* Mr. Teale now makes his flaps, as in Fig. 71, wider than he originally 
did. I have to thank him for altering this drawing with his own hand for 
this work. 



THE EYELIDS. 209 

is to reunion of the surfaces, unless one or both of them be car- 
peted with epithelium. 

In Teale's Operation, if we suppose the case to be similar to 
that represented in Fig. 70, an incision is carried along the line 
of the margin of the cornea at A, through the whole thickness of 
the symblepharon, and the lid is dissected off from the eyeball as 
far as the fornix. Two conjunctival flaps are now formed, as 
at B and C in Fig. 71, and one of them (B) is turned to form a 
covering for the wounded surface of the inside of the eyelid, while 
the other (C) is used to cover the bulbar surface (Fig. ^2) , the 
flaps being held in their places by fine sutures. That part of 
the symblepharon which is left adherent to the cornea soon at- 
rophies and disappears. No great tension of the flaps should 
exist as they Ue in their new positions. 

Teale, again, has suggested the formation of a bridge-like con- 
junctival flap above the cornea, and the removing of it across the 





Fig. 72. Fig. ys- 

latter to cover the loss of substance situated below. After the 
sutures to keep the flap in its place have been introduced, the 
latter is separated at its bases. 

A simple plan, which v;ould be applicable to such a case as that 
depicted in Fig. 70, where the adhesion is not very extensive, and 
perhaps even to some more extensive ones, consists in dissecting 
the conjunctival process oft' the cornea, and then turning it down 
on the raw inner surface of the under lid, and fastening it there 
with a suture or two. I have done this with complete satis- 
faction. 

Harlan's Operation^- — This is especially applicable to exten- 
sive symblepharon of the lower lid, and differs from the foregoing 
operations in that it provides a covering of skin, and not of mucous 
membrane, for the raw surface of the under lid. Operations on 
the same principle have been proposed by Snellen and by Kuhnt. 

18 



2IO DISEASES OF THE EYE. 

An incision (A B, Fig. 73) through the whole thickness of the 
eyelid, and corresponding in length to the latter, is made along 
the lower margin of the orbit. Below this a skin flap (CD) is 
then formed. The flap is dissected up, and the incisions are 
carried a little more deeply as A B is approached, to enable the 
flap to turn the more readily. The flap is then turned up as on a 
hinge, slipped through the buttonhole, and sutured securely to the 
inner surface of the under lid. After a time the skin surface 
turned towards the eyeball becomes considerably modified, so as to 
be somewhat like mucous membrane. The bare space left by the 
removal of the strip of skin is covered without strain by making 
a small horizontal incision (D E) at its outer extremity, and 
forming a sliding flap. 

Transplantation Operations. — The transplantation of a portion 
of mucous membrane from the lips or cheek, as employed by 
Stellwag, is a useful method for many cases of extensive sym- 
blepharon. The chief precautions necessary for success in this pro- 
ceeding are: That the flap to be transplanted be not applied in 
its new position until all bleeding at the latter place has ceased. 
That the flap be nothing more than mucous membrane, all sub- 
mucous tissue being carefully removed. That it be sufficiently 
large to cover the defect without any stretching; and it should 
be remembered that the flap shrinks to two-thirds of its size after 
being detached from its own bed. That the flap be kept moist and 
warm during the period — as short as possible — which may elapse 
between its detachment and its adjustment. And, finally, that it 
be kept firmly in its new position by a sufficient number of points 
of interrupted suture. It is seldom possible in extensive cases of 
symblepharon to do all that is necessary at one sitting. 

A drawback to mucous membrane flaps, where two opposing 
surfaces have to be covered, consists in the liability there is, when 
the superficial epithelium of the mucous membrane is thrown off, 
for the surfaces to unite. Hence some operators prefer to trans- 
plant Thiersch grafts, which are not open to this objection; or, 
mucous membrane may be used for one surface and Thiersch 
grafts for the opposite surface. In order to keep the grafts in 
position it is desirable, when possible, to insert an artificial eye, 
or some such support, into the socket. 

Blepharophimosis(/5Af'(pa'por, eyelid; cpijUGoffi?, narrozmng) is 
a contraction of the outer commissure of the lids, with consequent 
diminution in size of the opening between the latter ; and is com- 



THE EYELIDS. 



211 



monly due to shortening of the skin, from long-continued irrita- 
tion of it, caused by the discharge in a case of very chronic con- 
junctivitis. 

It is remedied by a Canthoplastic Operation. The outer com- 
missure is divided in its entire thickness, in a hne which is a pro- 
longation of the line of junction of the lids when closed, by a single 
stroke of a strong straight scissors, one blade of which has been 
passed behind the commissure. The integumental incision should 
be made a little longer than that in the conjunctiva. An assistant 
then drawls the upper lid up and the lower lid down, so as to make 
the wound gape. The conjunctival margin and the dermic mar- 




FiG. 74 — (de Weckcr), 



gin are now united in the center by a point of suture (C, Fig. 74), 
while two more sutures (A and B) are applied, one above and the 
other below the first. This operation is also employed in cases of 
granular ophthalmia and of purulent conjunctivitis when it is de- 
sired to relieve the pressure of the lid on the globe. 

Distichiasis {Sk, tiince; (jrixo?,a rozi') and Trichiasis(Tp/jo?, 
a hair). — The first of these terms indicates the growth of a row of 
eyelashes along the intermarginal portion of the lid in addition to 
the normal row ; while trichiasis indicates a false direction given 
to the true cilia. Both conditions are often found coexisting, and 
often, too, they are present along with entropium. They may both 
be produced by chronic blepharitis or by chronic granular oph- 



212 DISEASES OF THE EYE. 

thalmia. It has been commonly held that cicatricial contraction, 
giving a false direction to the hair follicles, is the immediate cause 
of these conditions ; but Raehlmann has recently ^^ shown that the 
false cilia are developed as buds or offshoots from the follicles of 
the cilia, and primarily from the cuticle of the free margin of the 
lid. The latter mode of development is a novel discovery by 
Raehlmann, which he seems to have definitely proved by his patho- 
logical investigations. His view is that hyperemia of the margins 
of the lids, and inflammation of a proliferating type are what give 
rise to this primary development of hairs. The symptoms they 
produce, and the dangers to the eye attendant on them, are due to 
the rubbing of the irregular eyelashes on the cornea, which pro- 



FiG. 75. 

duces pain, blepharospasm, and opacity of the cornea, or even 
ulceration of it. 

O perations for Distichtasis and Trichiasis: 

Epilation. — The false cilia may be pulled out with a forceps; 
but this cannot be regarded as a cure, for the hairs grow again. 

Ele^cfrolysis has been proposed by Charles Mitchell, of Mis- 
souri,^* and by Arthur Benson, of Dublin.^^ A needle is attached 
to the negative pole, and its point passed into the bulb of the eye- 
lash to be removed, the positive pole being placed on the temple. 
On closure of the circle, if the battery be working properly, 
bubbles of gas should rise up round the needle, and a slough forms 
at the root of the hair, which becomes loose, and is removed. It 
does not grow again, for the bulb is destroyed. Each hair must 
be separately operated on. The proceeding is very valuable where 
only a few cilia are to be dealt with. 

lllaqiietio. — Snellen has revived this ancient operation for cases 
where only a few isolated hairs are out of order. Both ends of a 



THE EYELIDS. 213 

bit of very fine silk thread are passed through the eye of a fine 
needle, so as to form a loop. The needle is now entered as close 
to the point of exit of the hair as possible, and the counter-puncture 
is made in the position which the hair should normally occupy 
in the row of its fellows. The needle is drawn completely 
through, as also the ends of the thread, but the loop not as yet. 
Into the loop the eyelash is now inserted by aid of a fine forceps, 
and by traction on the ends of the thread, loop and eyelash are 
drawn through the tunnel. Unfortunately the eyelashes fre- 




FiG. 76. 

quently regain their abnormal position by reason of their own 
elasticity. 

Excision. — When some half-dozen hairs close together are grow- 
ing wrong, the simplest and best plan is to completely remove them 
by excision of the corresponding portion of the ciliary margin. 
A fine knife is passed into the intermarginal region at the place cor- 
responding to the hairs to be dealt with, and a partial division 
of the lid into two layers, as in the Arlt-Jaesche operation (vide 
infra) , is effected. A V-shaped incision in the skin of the lid 
is then made, including the erring hairs, the whole flap is excised, 
and the margin of the loss of substance drawn together with 
sutures. 



214 



DISEASES OF THE EYE. 



In cases of distichiasis or trichiasis involving the whole length 
of the eyelid, removal of the marginal portion of skin containing 
the bulbs of all the eyelashes, true and false (Flarer's operation), 
is not to be recommended — unless, occasionally, in the under lid 
— because it unnecessarily deprives the eye of an ornament, and 
of a protection against glare of sun and foreign bodies. 

Transplantation, or Shifting, of the marginal portion of the in- 
tegument containing the hair bulbs, true and false, is a prefer- 
able proceeding in these complete cases. One of the oldest and 
most valuable operations of this kind is that of Jaesche, modified 
by Arlt. It is performed as follows : Knapp's, or Snellen's, clamp 
(Fig. 75) having been applied to prevent bleeding, the lid in its 
whole length is divided in the intermarginal part into two layers 





Fig. 77- 



Fig. 78. 



(Fig. 76), the anterior containing the orbicular muscle and in- 
tegument with all the hair bulbs, the posterior containing the tar- 
sus and conjunctiva. The incision in the intermarginal portion 
is about 5 mm. deep. A second incision is now made through the 
integument of the lid, parallel to its margin, and from 5 to 7 mm. 
removed from it. This incision also extends the whole length of 
the lid. A third incision is carried in a curve from one end to the 
other of the second incision. The height of the curve is pro- 
portional to the effect required, varying from 4 mm. to 7 mm. The 
piece of integument included between the second and third in- 
cisions is dissected off with forceps and scissors, without any of 
the underlying muscle being touched, and the margins of the loss 
of substance are brought together by sutures. By this procedure 



THE EYELIDS. 215 

the lower portion of integument, containing the hairs and their 
bnlbs, is drawn up and away from contact with the cornea. 

]\Iany double transplantation operations have been proposed ; 
of these : 

Dianoux's Operation ^^ is as follows: Snellen's (or de Weck- 
er's) clamp is applied (omitted in figures for simpHcity), and an 
incision (Fig. yy) is made parallel to the free margin of the Hd, 
about 4 mm. from it, extending the whole length of the lid, and 
penetrating to the tarsus, but not through the latter. The ciliary 
portion of the lid marked off by this means is now detached from 
the tarsus by an incision in the intermarginal portion of the lid, as 
in the Arlt-Jaesche operation. An incision through the skin alone 
is then made about 3 mm. above the first incision and parallel to it, 




Fig. 7( 



but extending some 2 mm. beyond it at either extremity. The 
skin flap is separated off from the underlying muscle, except at 
either end, where it is left attached. The underlying portion of 
the muscle is then separated from the tarsus, and allowed to re- 
tract upwards. A forceps is passed under the ciliary flap (Fig. 
yy), and the skin flap is seized and drawn down into the position 
of the former (Fig. 78), where it is made fast by three sutures 
to the margin of the tarsus. The ciliary flap is moved up, and 
carefully stretched upon the tarsus bared of the orbicularis, the lat- 
ter being drawn back with a strabismus hook, and the flap is se- 
cured in its place by sutures to the tarsus. An antiseptic dressing 
is applied, and the sutures may be removed on the third day. Al- 
though the wounded surface of the ciliary flap does not become 



2i6 DISEASES OF THE EYE. 

vitally united with the epirlermic surface of the skin flap, yet no 
practical ill result follows. 

A real objection lies in the circumstance that occasionally the 
cutaneous hairs on the transplanted flap irritate the cornea, and 
these hairs, being much finer than cilia, are more difficult to deal 
with. 

Vossiiis' Operation}'^ — If, for example (Fig. 79), the whole 
extent of the right upper lid be affected with trichiasis, a horn 
lid-spatula (the clamp will not answer) is passed under the lid, and 
held by an assistant. An intermarginal incision is made, as in the 
Arlt-Jaesche operation, about 3 mm. to 4 mm. deep. This incision 
is then prolonged through the skin merely, over the external com- 




FiG. 80. 

missure for 5 mm. to 6 mm. It is then turned upwards at an 
angle of about 35° with the free margin of the lid, and a flap 
about 5 mm. wide is marked out with the knife in the usual 
crease or fold of the upper lid. A narrow, sharp, and pointed 
scalpel is then thrust under the flap at its base, and carried 
towards its inner end, so as to separate it ofif without the aid of 
forceps, scissors, or any other instrument. The margins of the 
wound thus made are brought together with four or five sutures, 
and the flap turned down and secured in the gaping intermarginal 
incision by means of four or five suturcj between each of its edges 
and the corresponding palpebral margin: One suture fastens the 
free end of the flap in the median corner of the wound. The posi- 
tion of the cicatrix, just in the fold of the upper eyelid, prevents 



THE EYELIDS. 217 

its causing any disfigurement. Were the case one of partial tri- 
chiasis, the intermarginal incision should extend a little beyond 
the point where the abnormal condition ceases. If it be the inner 
half only of the margin of the lid which is affected, the intermar- 
ginal incision is prolonged towards the nose, and the flap so 
formed that its base lies over the inner canthus. The flap heals 
in readily, and, although it shrinks somewhat, secures a wide 
intermarginal portion. The same drawback in connection with 
the cutaneous hairs on the transplanted flap holds good here as in 
Dianoux's operation. 

Van Millingens Operation ^^ consists in splitting the eyelid, 
as in the Arlt-Jaesche operation, from end to end, sufficiently 
to produce a gap {B, Fig. 80) 3 mm. in width at the central part 
of the lid, and gradually becoming narrower towards the canthi. 
The gap is kept open by sutures passed through folds of skin on the 
upper lid {a a a), by means of which also the lid is prevented from 
closing for twenty-four hours at the least. As soon as the bleed- 
ing has ceased, a strip of mucous membrane of the same length 
as that of the lid, and 2 to 21-2 mm. in breadth, is cut out with 
two or three snips of a curved scissors from the inner surface of 
the patient's under lip, and is placed at once into the gap in the 
intermarginal space. It should then be pressed into position with 
a pledget of cotton-wool steeped in sublimate solution (i in 5000). 
According to Van Millingen, sutures are superfluous ; but I like 
them for the sake of security, and I do not find that they do harm. 
The eyelid is then covered over with a piece of lint, on which is 
spread a thick layer of xeroform vaselin, and on this is placed a 
wad of cotton-wool and a bandage. Both eyes should be band- 
aged. The sublimate lotion is used for disinfecting the eye and 
lip during, before, and after the operation. The dressing should 
be renewed once in twenty-four hours, and the sutures in the upper 
lid ought not to be removed before the second day. 

Van Millingen does not think it advisable to transplant small 
strips of mucous membrane if the trichiasis be partial. He re- 
gards this condition as only the commencement of complete 
trichiasis, and therefore recommends, even in these cases, the fill- 
ing up of the entire length of the intermarginal space with a flap 
of mucous membrane. In cases of shortening of the conjunctival 
surface, in which it has been reduced to 1-2 cm., a strip of mucous 
membrane measuring 4 mm. in width at the center may be trans- 
planted. 



2i8 DISEASES OF THE EYE. 

The strip to be transplanted is generally taken from the angle 
of the lip and from the line of demarcation between the dry and 
moist surfaces of the lip. A couple of fine sutures, which serve 
to unite the margins of the wound in the lip, arrest the bleeding at 
once, and accelerate union of the part, which is generally com- 
pleted in twenty-four hours. 

The transplanted tissue in this instance being free from hairs, 
the method is not open to the objection referred to in Dianoux's 
and Vossius' operations, while it is equally effectual in perma- 
nently providing a good intermarginal space and in thus perma- 
nently relieving the condition. 

Entropium {sv^in; rpenQo^ to turn), or Inversion of the Eye- 
lid, is due to some organic change in the conjunctiva or tarsus, or 
to spasm of the palpebral portion of the orbicular muscle. 

A large proportion of the former class of cases is the result of 
chronic granular ophthalmia, and is most common in the upper 
Ud. 

Spastic entropium occurs in the under lid only. It is frequent 
in old people (senile entropium) from relaxation of the skin of the 
eyelid, and is also produced by the wearing of a bandage after 
operations, etc., and by edema of the conjunctiva in inflammation 
of that membrane. 

Treatment. — Organic entropium, in which tarsus of the upper 
lid is not distorted, can often be corrected by one of the methods 
described for trichiasis and distichiasis. But many of these cases 
are accompanied by, or rather are clue to, abnormal curvature with 
hypertrophy of the tarsus. 

In all such cases the operation must include an attack on the 
tarsus itself, or the result will be abortive. Indeed, I have little 
doubt that much of the disappointment experienced in the treat- 
ment of entropium has been due to imperfect appreciation of this 
fact. 

StreatH eld's Operation is as follows: The clamp having been 
applied, an incision is made through the integument of the eyelid 
parallel to its margin, 2 mm. distant from the latter, and extend- 
ing its whole length. The muscle is dissected up so as to lay 
bare the tarsus, and then a wedge-shaped piece, 2 mm. wide and 
the length of the lid, the edge of the wedge pointing towards the 
inner surface of the lid, is excised from the tarsus. A correspond- 
ing portion of muscle and skin is also removed, and the wound is 
allowed to heal by granulation. The shrinking of the resulting 



THE EYELIDS. 



219 



cicatrix causes the marginal portion of the tarsus to return to its 
correct position. 

Snellen's Operation. — Snellen's clamp (very similar to Knapp's, 
which can equally well be used) is applied. About 3 mm. from 
the margin of the lid, and parallel to it, an incision is made 
through the skin alone, extending the whole length of the lid. The 
orbicular muscle is exposed by dissection of the skin upwards, in 
order to promote retraction of the latter, and along the edge of the 
lower margin of the wound a strip about 2 mm. broad of the orbi- 
cular muscle is removed, and the tarsus to the same extent exposed 
to view. A wedge-shaped piece corresponding to the exposed part 
of the tarsus is now excised from it with a very sharp scalpel or 
Beer's cataract knife, the edge of the wedge pointing towards 





Fig. 81. 



Fig. 82. 



the conjunctiva, which latter, however, is left intact. The hyper- 
trophy of the tarsus, which is always present, facilitates this pio- 
cedure. A silk suture carrying a needle on each end having been 
prepared, one needle is passed from within outwards through 
the band of muscle and integument left at the margin of the lid. 
The second needle is also passed from within outwards through 
the upper lip of the tarsal loss of substance, and then from within 
outwards through this same marginal band, at a distance of about 
4 mm. from the point of exit of the first needle. The ends of the 
structure are now tied together, a small bead having first been 
strung on each to prevent it from cutting through the skin. Three 
such sutures are employed. The accompanying figures (81 and 
82) make the foregoing description more intelligible. 

Green's Operation}^ — An incision is made on the inner sur- 



220 DISEASES OF THE EYE. 

face of the lid in a line parallel to, and about 2 mm. distant from, 
the row of openings of the Meibomian ducts. It is carried through 
the conjunctiva and whole thickness of the tarsus, and should ex- 
tend, in cases of complete entropium, from near the inner to the 
outer canthus. A strip of skin about 2 mm. broad, and tapering 
to a point at each end, is now excised from the lid, — the lower 
margin of the strip being i 1-2 mm. above the line of the 
eyelashes. The muscle is left intact. Fine silk sutures are 
applied in the following manner by aid of a No. 12 glover's 
needle bent to an arc of about a third of a circle: The 
needle is first introduced a little to the conjunctival side of the 
row of eyelashes, and is brought out just within the wound made 
by the excision of the strip of skin (A, Fig. 83) ; it is then drawn 
through, inserted again in the wound near its upper margin, and 




Fig. 83. 

passed deeply backwards and upwards so as to graze the front of 
the tarsus, and emerge through the skin a centimeter or more 
above its point of entrance (B, Fig. 83). On tying the two ends 
of the thread together, the skin-wound is closed, and the loosened 
lid-margin is at the same time everted and brought into a correct 
position. Three sutures generally suffice for the accurate adjust- 
ment of the lid-margin. In the spaces between and beyond the 
sutures it is often practicable and advantageous to turn the eye- 
lashes upwards against the front of the eyelid, and fix them there 
by means of collodion. The stitches should be removed at latest 
on the day after the operation, the line of suture being then 
strengthened by collodion, or, in case the cilia are very short, a 
few short fibers of cotton are used with the collodion. 

BcrUris Operation. — Knapp's clamp is applied. The first in- 
cision lies 3 mm. above the margin of the lid, extends its whole 
length, and divides it in its entire thickness, including the con- 
junctiva. The skin and muscle at the upper edge of the wound 



THE EYELIDS. 221 

are pushed or dissected up so as to expose the tarsus. The upper 
edge of the tarsal incision is now seized at its center with a finely 
toothed forceps, and an oval piece with the adherent conjunctiva, 
about 2 to 3 mm. wide in its widest part, and in length corre- 
sponding with that of the eyelid, is excised from it with a fine 
scapel. The wound is closed with three sutures through the skin. 
If it be thought desirable to increase the efifect, a skin-flap may be 
excised from the lid. The objection to this operation, that a por- 
tion of the mucous membrane is removed, is not of importance. 
Except for an occasional granulation forming on the bulbar aspect 
of the wound, I have found the operation free from inconvenience, 
and its result satisfactory, and in most instances permanent. 

Spastic Entropium, as the result of bandaging, usually disap- 




FlG. 84. 

pears when the use of the bandage is given up, or, if the bandage 
must be continued and should the inverted lid cause irritation, an 
epidermic suture at the palpebral margin and fastened to the 
cheek below will give relief. 

Senile Entropium of the lower lid is, of the spastic kinds, the 
one which most commonly demands operative interference. The 
methods in general use for it are : 

The Excision of a Horizontal Piece of Skin, with a portion of 
the underlying orbital part of the orbicular muscle, so as to give 
rise to sufficient cicatricial contraction to draw the margin of 
the lid outwards. 

The application of Subcutaneous Sutures (Gaillard's Sutures). 
— The point of a curved needle carrying a silk suture is entered 
in the center of the lid near its margin, passed deeply into the 



222 



DISEASES OF THE EYE. 



orbicular muscle, brought out at a point some lo mm. below, and 
the suture tied tightly. Two more similar sutures, one on either 
side of the first and about 5 mm. distant from it, are placed. The 
sutures are allowed to remain for a week or more, and the result- 
ing cicatrization brings the lid into its position. 

Von Graefe's Operation. — 3 mm. from the margin of the lid an 
incision is made, as in Fig. 84, through the skin, and a triangular 
skin flap (A) excised. The edges B and C of the triangle are 
dissected up a little and brought together by three points of suture, 
while the horizontal incision is not sutured. The size, especially 
the width, of the triangular flap to be excised is proportional to the 
looseness of the skin. When a very marked effect is desired, the 
flap to be removed is given the shape as represented at the right 




Fig. 85. 



of the figure. I have found this proceeding extremely satisfac- 
tory, and its result, as a rule, permanent. 

All the foregoing and other such measures produce a good re- 
sult at the time, but are sometimes followed by recurrence of the 
entropium. Holtz believes the cause of this to be that the cicatrix, 
be it dermic or dermo-muscular, upon which the result depends, 
has no point d'appiii; and consequently, while it may draw the 
eyelid out, it is just as liable to draw the skin of the cheek up, 
and thus neutralize its desired effect. He proposes the following 
ingenious operation : 

Holtz s Operation}^ — A horn spatula is inserted under the lid, 
and then, at 4 to 6 mm. below the margin of the latter, a hori- 
zontal incision is made through the skin from the inner to the outer 



THE EYELIDS. 223 

end of the lid. This incision is at the boundary between the 
palpebral and orbital portions of the orbicular muscle, and just 
over the lower margin of the tarsus. An assistant then draws the 
upper edge (a. Fig. 85) of the wound upwards with a forceps, 
while the surgeon draws the lower edge (b) downwards, in this 
way exposing and stretching the orbicular muscle. A few strokes 
of the knife in the direction of the incision are now sufficient to 
separate the palpebral portion (/) of the muscle from the orbital 
portion (p), and to lay bare the lower edge of the tarsus (t), 
which has a yellowish tendinous appearance. That part of the 
palpebral portion of the muscle which covered the lower edge of 
the tarsus, and which was drawn up with the palpebral edge of 
the first incision, is now removed with forceps and scissors, to 
the extent of about 2 mm. in width, through the whole length 
of the lid. All such muscular fibers, also, which may still adhere 
to the lower third of the tarsus must be carefully cleaned off, and 
now the palpebral skin may be brought into union with the tarsus. 
Four sutures are generally applied, about 5 mm. apart. The needle 
is passed through the palpebral skin, close to the margin of the 
wound (at a). The bare tarsal edge is then seized in the forceps, 
the needle placed perpendicularly on it (at t/), and carried through 
it by a short downward curve until its point appears (at c) below 
the tarsus in the tarso-orbital fascia (/). The needle is now passed 
out through the lower edge of the incision (at b), care being 
taken that none of the fibers of the orbital portion of the muscle 
are included in the suture. Upon the suture being tightly closed, 
the edges of the skin wound are drawn into the tarsus, and be- 
come adherent to it. The sutures may be removed about the 
third day. If the first incision be placed too far from the margin 
of the lid, there will be no result, as the traction upon the pal- 
pebral skin will be too slight. If the incision be placed too close 
to the margin, the traction may be so great as to interfere with the 
union of the skin and tarsus. In this operation the tarsus affords 
the fulcrum, which Holtz thinks is wanting in other methods. The 
tarsus of the lower lid is sometimes very little developed, and then 
I find the result of the operation may be disappointing. 

Ectropium or Eversion of the Eyelid. — Of this there are two 
chief kinds : ( i ) ]^Iuscular, or Spastic, which affects the lower 
lid only; (2) Cicatricial. 

Muscular ectropium may be caused by edema of the conjunctiva, 
which everts the edge of the lower eyelid, and this eversion i-s 



224 DISEASES OF THE EYE. 

increased and encouraged by spasm of the palpebral portion of the 
orbicular muscle, so that the term palpebral paraphimosis might 
be given to the condition. In the recent stage it may generally 
be remedied by a properly applied bandage, combined w^ith the 
suitable conjunctival measures. In chronic cases operative meas- 
ures may be required. 

Muscular ectropium is often seen in old people, and is then 
given the name of Senile Ectropium. Here it is due to atrophy 
of the palpebral portion of the orbicularis of the lov^er lid and 
relaxation of the skin of the face. When these have resulted in 
slight eversion of the inferior punctum, a flowing of tears is pro- 
duced, causing excoriations of the skin and edge of the Ud, 
which then, in their turn, increase the tendency to ectropium. If 
the condition be not extreme, with secondary changes in the 
conjunctiva, slitting up of the canaliculus, with the use of a boric 
ointment for the lids and mild astringents for the conjunctiva, will 
give much relief. In pronounced cases a more active treatment 
of the conjunctiva, and the performance of tarsorrhaphy, or the 
latter preceded by the application of Snellen's sutures, or Kuhnt's 
operation, are demanded. Muscular ectropium is also caused by 
paralysis of the orbicular muscle. 

Snellen s Sutures. — A silk ligature is threaded at either end 
with a needle of moderate size and curve. The point of one 
of these needles is passed into the most prominent point of the 
exposed and everted conjunctiva, and brought out through the skin 
2 cm. below the edge of the lower lid. The other needle is en- 
tered in the same way 5 mm. from the first, and made to take a 
nearly parallel course, the points of exit on the cheek being i cm. 
apart. Equal traction is applied to each end of the suture, while 
the lid is assisted into its place by the finger. The suture is tied 
on the cheek, a small roll of sticking-plaster having been inserted 
under it, to protect the skin from being cut. Two, or even three, 
such sutures may be required, and they are allowed to remain for 
several days. 

Kuhnt's Operation ^^ for Senile Ectropion is an admirable one. 
It consists in splitting the lower lid in its central third, so that 
the conjunctiva and tarsus are left in the posterior layer, while the 
anterior layer contains the orbicularis and the skin. A triangular 
piece, the base of which is formed by the margin of the lid, 
is then excised from the posterior layer, and the margins of the 
loss of substance in the latter are brought together by three or 



THE EYELIDS. 



225 



four points of suture. Lest they should give way too soon, it is 
necessary to place these sutures very securely. A puckering of 
the anterior layer, opposite the line of sutures in the posterior 
layer, is produced, but subsequently disappears, and a suture which 
unites the most prominent point of the pucker and the margin of 
the tarsus assists in this. Or, if the lid be split, say, to an extent 
twice as long as the base of the triangular piece to be excised, the 
puckering can be distributed at either end of the incision. By 
reason of the shortening of the lid as the result of this excision the 




Fig. 86. 



eversion is corrected. I have repeatedly used this operation, and 
always with gratifying results. 

Argyll Robertson s Operation - has been designed for those 
cases of ectropium which result from long-continued chronic in- 
flammation of the conjunctiva of the lower lid. He thinks the 
difficulty in severe cases of this kind depends upon the abnormal 
curvature which is gradually acquired by the tarsus. The fol- 
lowing is his description of the operation, from which he has ob- 
tained satisfactory results : 

The materials required are : 

I. A piece of thin sheet-lead about i inch long and 1-4 inch 
broad, rounded at its extremities, and with its cut margins 

19 



226 DISEASES OF THE EYE. 

smoothed. This piece of lead must be bent with the fingers to a 
curvature corresponding to that of the eyeball. 

2. A waxed silk ligature about 15 inches long, to either extrem- 
ity of which 2. long, moderately curved needle is attached. 

3. A piece of fine india-rubber tubing of the thickness of a fine 
drainage-tube. 

The operation is performed by perforating the whole thick- 
ness of the lid with one of the needles at a point {h, Fig. 86) 
one line from its ciliary margin, and a quarter of an inch to 
the outer side of the center of the lid. The needle, bavins: been 
drawn through (at a), is passed directly downwards over the con- 
junctival surface of the lid till it meets the lower conjunctival 
fornix, through which the needle is thrust — the point being di- 
rected slightly forwards — and pushed steadily downwards under 
the skin of the cheek, until a point (d) is reached about i inch or 
I 1-4 inch below the edge of the lid, when the needle is caused 
to emerge, and the ligature is drawn through. The other needle is, 
in like manner, thrust through the edge of the lid at a correspond- 
ing point {h') a quarter of an inch to the inner side of the middle 
of the lid, then passed over the conjunctival surface of the lid, 
through the fornix, and downwards under the skin, till the point 
emerges at a spot {d') a quarter of an inch outwards from the 
point of exit of the first needle {d). The ligature is kept slack, 
or is slackened so as to permit of the piece of lead being intro- 
duced under the loops of the ligature that pass over the conjuncti- 
val surface of the lid, and of the piece of india-rubber tubing (c) 
being slipped under the loop at the edge of the lid (between h and 
b'). The free ends of the ligature are now drawn tight, and tied 
moderately tightly over a lower part of the india-rubber tube ; the 
excess of india-rubber tube is cut off — about three-quarters of an 
inch beyond the ligature — and the operation is complete. 

The result of the procedure is that the edge of the lid is 
made to revolve inwards over the upper edge of the piece of lead, 
while the tarsus is caused to mold itself to the curve of the lead, 
and the eyelid at once occupies its normal position. A certain 
amount of redness and edema of the lid follows the operation, and 
suppuration occurs in the track of the ligature ; but as the india- 
rubber tube yields somewhat to the tension on the ligature, the re- 
sulting irritation is moderate, so that the apparatus need not be 
removed for five, six, or seven days, by which time the tarsus has 
become pretty well fixed in its new curvature. A slight relapse 



THE EYELIDS. 



227 



may occur when the apparatus is removed, but this is readily 
amenable to treatment by astringent applications. 

The suppuration occurring in the tracks of the ligature leads 
to cicatricial formation, which appears to impart a degree of rigid- 
ity to the lid that helps to keep the latter in its new position. 

Kenneth Scotfs Operation}^ — The external canthus and tissues 
beyond are thoroughly divided by a pair of strong scissors ; the 
lower eyelid, which is usually the affected one, is then seized 
and its margin stretched sufficiently outwards, parallel to the 
border of the other lid, so as to restore the palpebral aperture to 
its proper appearance; the portion of eyelid margin thus made 
to extend beyond the site of the external canthus is removed, 
along with its contained eyelashes, by slicing it with a sharp knife. 




Fig. 87. 



Fig. 88. 



The upper and lower eyelids are then brought together, so that 
the original outer extremity of the one approximates exactly to 
the new extremity of the other eyelid. They are secured in this 
position by passing a silver wire suture vertically downwards 
through the substance of the upper lid, continuing it out through 
that of the lower one, and then twisting the ends firmly togeth"er. 
Two of these retaining stitches may be introduced close together if 
necessary. The edges of divided skin, along with the deeper mus- 
cular tissues, including that part which recently formed the outer 
end of the affected eyelid, are simply stitched together with a con- 
tinuous fine silk suture. 

No dressing other than a repeated dusting with some fine 



228 DISEASES OF THE EYE. 

antiseptic powder need be used. The silk stitches may be re- 
moved in six days' time, the silver ones being left in for five 
or six days longer. Dr. Scott states there is never any puckermg 
apparent beyond the newly formed canthus, and the small linear 
cicatrix is lost amongst the other lines often found there. 

Cicatricial Ectropium is caused by scars from wounds or burns, 
or from caries of the orbit, and can only be relieved by opera- 
tion. 

Wharton Jones's Operation is as follows : The cicatrix is cir- 
cumscribed by a V-shaped incision (Fig. 87), and the skin made 
thoroughly movable in its neighborhood. The edges of the 
wound are now brought together so as to form a Y (Fig. 88). 

Arlt's Operation for cases due to caries of the margin of the 
orbit. — If the cicatrix be situated at e (Fig. 89), the incisions at 
a b and b c are made through the skin and muscle, so that an 
acute, or at most a right, angle is formed at b. The margin 




Fig. 89. 

of the lid from c to (/ is excised. The cicatrix is completely un- 
dermined, and the triangle dissected up from b to the margin of 
the tarsus, so that the lid can be readily put into its position, and 
the edge c b oi the flap united to d c. The size of the exposed 
surface on the cheek can, according to Arlt, be diminished by 
drawing its edges together after the manner of a hare-lip, but 
possibly the transplantation of a piece of skin from the arm to fill 
the gap might be a better plan. 

The foregoing and similar operations are difficult or impossible 
in many cases where there has been great destruction of the skin 
of the eyelids and surrounding parts by burns, ulcers, etc., and at 
best the deformity is liable to recur. Transplantation of skin 



THE EYELIDS. 229 

from different parts of the body is in these cases a more promising 
proceeding. A description of the method is given in the next 
paragraph but one. 

Ankyloblepharon {dyuvXi/, a string; f5Xeq)apov^ an eyelid) 
is a uniting of the upper and lower eyelids along their margins. 
It may be partial or complete, and often goes with symblepharon. 
Like the latter, it is usually caused by burns and ulcers. 

The condition can only be relieved by operation, of which the 
result is often unsatisfactory, owing to the difficulty of preventing 
reunion taking place. To avert this it is always necessary to 
cover the wounded surface with conjunctiva or skin. 

The Restoration of an Eyelid. — It is an extremely rare event 
for the whole substance of one or both eyelids to be destroyed 
by lupus, or other ulceration, or by accidents, which do not at the 
same time injure the eyeball seriously. In this rare event the 
eyeball, especially if the upper lid be destroyed, is exposed ; the 
patient is subject to extreme discomfort ; and, owing to ulcera- 
tion of the cornea, the eye is ultimately lost. 

The formation of an eyelid from the skin of the forehead or 
cheek in these cases is a most disappointing proceeding, and one 
the description of which does not, I consider, come within the 
scope of this book. Indeed, my own feeling in such a case would 
be to recommend enucleation of the eyeball, provided the fellow- 
eye were good, rather than to propose a plastic operation which 
at the best would give but an imperfect result. 

Fortunately the class of cases with which we commonly meet 
are essentially different in their nature ; for in them the whole 
thickness of the eyelid is not destroyed. They are usually the result 
of burns (epileptics and children falling in the fire) and scalds 
which only destroy the integument of one or both eyelids. A 
granulating surface replaces the skin, and when healing com- 
mences the shrinking process draws the free margin of the upper 
eyelid up towards the eyebrow, and that of the lower lid down 
towards the cheek, the conjunctival surface of the eyelids becom- 
ing everted, and the cornea exposed, as the eyelids cannot now 
be closed. We have a satisfactory method for dealing with 
these cases. 

In the first place the eyelid — let us suppose it to be the upper 
eyelid — is dissected down into its place to the utmost limit, so 
that the most extensive raw surface possible may be obtained. 
The margin of the lid is now fastened to the cheek with three 



230 DISEASES OF THE EYE. 

points of suture. A portion of skin, suited as regards shape, and 
one-third larger (to allow for shrinkage) than the raw surface of 
the eyelid, is then taken from the inside of the arm, and after 
being carefully freed of all its subcutaneous fat and connective 
tissue, is laid upon the raw surface and fastened to it by a large 
number of fine sutures around the margin. Or, if the margin 
of the skin surrounding the raw surface be dissected up, the edge 
of the graft can be slipped under it, and secured in its place by 
this means. A non-irritating antiseptic dressing is applied, and 
the graft usually heals on in the course of a few days. This 
method of grafting was introduced by Wolfe and Lefort, and I 
have employed it many times with most satisfactory results. 

It is most important to preserve and utilize any part of the 
eyelid which remains, especially its ciliary border with the eye- 
lashes. 

The flap sometimes becomes separated from the wounded sur- 
face by oozing of blood or serum from the wound, and then 
sloughs, and it is important not to apply the graft until all hemor- 
rhagic oozing has ceased. To obviate any such separation, Wick- 
erkiewicz has employed secondary transplantation with satisfactory 
results. The flap is applied to the wounded surface from two to 
five days after the latter has been prepared, while during the in- 
terval the wounded surface has been protected with moist anti- 
septic dressings. He states that union by first intention occurs 
readily by this method. 

The transplantation of a flap with pedicle from the forehead, 
temple, or cheek is also used to repair an eyelid ; but, owing to 
the thickness of the integument, the result is cosmetically less sat- 
isfactory than that given by a graft from the arm, while the tend- 
ency to shrink is quite as great. 

Sachs prefers Thiersch grafts to dermic grafts. He states they 
are more easily applied to the raw surface, and do not differ in 
color from the surrounding skin when healing is completed. He 
is careful to obtain one continuous graft of the whole size of the 
wounded surface. 

Injuries of the Eyelids.— All kinds of injuries of the eyelids 
(contusions, incisions, burns, etc.) are common. 

In consequence of the looseness of the integument, edema and 
ecchymosis, one or both, are often seen in a marked degree as the 
result even of slight injuries. 

Owing to the direction of the fibers of the orbicularis, an in- 



THE EYELIDS. 231 

cised wound of the eyelid, if in the vertical direction, will gape, 
while a similar wound in the horizontal direction will not do so. 
Hence the scar left after the former wound is apt to be very vis- 
ible, but that after the latter may be almost imperceptible. If the 
eyelid be divided vertically in its entire thickness, unless union 
by first intention can be obtained, a deep furrow is left in the 
eyelid, and, perhaps, at its margin an unsightly coloboma. 

Emphysema of the eyelids is sometimes seen after a blow 
on the eye, and is a sign of fracture of the orbit, with a com- 
munication between the subcutaneous connective tissue of the eye- 
lids and the nose, the ethmoid sinus, the frontal sinus, or the an- 
trum of Highmore. An emphysematous lid is swollen, soft, and 
crepitating to the touch. 

Ecchymosis of the lower lid, usually with ecchymosis of the 
lower conjunctiva, after falls or blows on the head, is a sign 
of fracture of the base of the skull, the blood making its way 
along the floor of the orbit. 

Simple ecchymosis of the eyelids from blows, commonly known 
as '' Black Eye," never gives rise to further complication. It re- 
quires some fourteen days or more, according to the quantity of 
blood extravasated, before the eye recovers its normal appear- 
ance. 

Treatment. — Injuries of the eyeUds, of whatever kind, are of 
course treated upon general surgical principles. Incised wounds 
should be carefully and neatly drawn together with sutures as soon 
after the injury as possible, and with antiseptic precautions. Em- 
physema may be assisted in its absorption by the application of a 
rather tight bandage, and directions should be given to the pa- 
tient to blow his nose as gently as possible, so as to avoid recur- 
rence of the emphysema. 

Epicanthus is a congenital deformity, usually binocular, which, 
in the most pronounced cases, consists in partial paralysis of the 
levator palpebrse (ptosis) and of the rectus superior, with a nar- 
row palpebral fissure, and a fold of integument at the inner 
canthus concealing the caruncle from view, and giving the appear- 
ance of great breadth to the bridge of the nose. The term is also 
used for cases in which the integumental fold at the inner canthus 
is the only abnormal condition, and this deformity can be some- 
what diminished by the removal of an oval piece of skin from the 
bridge of the nose, its long axis being vertical and its width 
varying according to the effect required. When the margins of 



232 



DISEASES OF THE EYE. 



the wound are brought together the abnormal folds are diminished 
in width. 

Congenital Coloboma of the upper lid, sometimes associated 
with a dermoid cyst of the limbus of the cornea corresponding to 
the cleft in the lid, and even congenital absence of the eyelids, 
have been occasionally observed. 



References. 

^ " Brain," 1900, p. 353. 

^ '' Practitioner," November, 1898. 

^ '' Centralblatt fiir praktische Augenheilkunde," 1892, p. 129. 

* " Archives d'Ophtalmologie," Janvier-Fevrier, 1886. 

^ " Von Graefe's Archiv, xxxvi. i. p. 234. 

^ " Klinische Monatsblatter fiir Augenheilkunde," 1883, p. lOO. 

^ " Archiv fiir Augenheilkunde," xxxiii. p. 125. 

^ " Archives of Ophthalmology," xxi. p. 354. 

" " Klinische Monatsblatter fiir Augenheilkunde," 1902, p. 527. 

^° " Roy. Lond. Ophthalmic Hospital Reports," xiv. i. p. 270. 

" " Von Graefe's Archiv," xiv. i. p. 270. 

^'"Ophthalmic Review," ix. p. 351. 

" " Von Graefe's Archiv," xxxvii. 2. p. 66. 

" " Trichiasis and Distichiasis, their Nature and Pathology, 
Radical Method of Treatment," 1882. 

^^ " British Medical Journal," December, 1882. 

" " Annales d'Oculistique," 1882, p. 132. 

" " Bericht der ophthalmologischen Gesellschaft." Heidelberg, 1887, 
p. 42. 

"* " Ophthalmic Review," 1887, p. 309. 

" " Trans. American Ophthalmological Society," viii. p. 167. 

'" " Klinische Monatsblatter fiir Augenheilkunde," 1880, p, 149. 

'' " Beitrage zur operativen Augenheilkunde." Jena, 1883. 

""Edinburgh Clinical and Pathological Journal," December, 1883; and 
" Ophthalmic Review," iii. p. 47. 

^^ " British Medical Journal," September, 1896. 



with 



CHAPTER VIII. 
DISEASES OF THE LACRIMAL* APPARATUS. 

Malposition of the Punctum Lacrimale.f — Inversion of the 
punctum accompanies entropion of the lower eyelid, while ever- 
sion of it is present with ectropium of the lid. A slight eversion, 
quite sufficient to cause epiphora, may exist without any marked 
ectropion of the lid, and it is these cases which more properly be- 
long to this chapter. They are the result generally of some 
chronic, although it may be slight skin affection of the lower lid, 
which draws the inner end of the latter a little away from the 
eyeball. 

The prominent symptom of this and of all the following lacri- 
mal affections is lacrimation, or epiphora {iniq)opa Saupvoov, 
a sudden hurst of tears), a flowing of tears over the cheek. 

Stenosis and Complete Occlusion of the Punctum Lacri- 
male. — Either of these conditions may result from conjunctivitis 
or from marginal blepharitis, although they may not appear for a 
length of time after those affections have passed away, and the 
original affection may have been so slight as to have escaped the 
observation of the patient. In stenosis the size of the punctum 
may become so extremely minute that even the normal flow of 
tears is too copious to pass through it. Complete occlusion is 
probably only a more advanced stage of stenosis. 

The treatment, in cases of eversion of the punctum, of stenosis, 
and of complete occlusion is similar, namely, the opening up of the 
punctum, and its conversion into a slit: this is done with a 
Weber's knife (Fig. 90), the probe-point of which is passed into 
the punctum in cases of eversion, forced into the small opening in 
cases of stenosis, or forced through the usually thin covering of 
the punctum in cases of occlusion. In doing this the lower lid 
should be stretched tightly by a finger of the surgeon's left hand 

* Lacrima, a tear. 

t In this chapter, and elsewhere in the book, the terms punctum 
lacrimale and canaliculus refer to the inferior passage, unless it be other- 
wise expressly stated. 

20 __ 



234 DISEASES OF THE EYE. 

placed near the external canthus. The edge of the knife being 
now directed towards the eyeball, the instrument is pushed on a 
little into the canaliculus, until 2 mm. of the latter has been 
opened up, and it is then withdrawn. If the edge of th^ 
knife be directed outwards in this proceeding, the incision 
comes to lie on the outer edge of the intermarginal portion 
of the lid, and not in contact with the eyeball ; consequently 
the tears are not carried away, and the disfigurement pro- 
duced is considerable. A slitting up of the whole, or the 
greater part, of the canaliculus in these cases is unneces- 
sary, and interferes with the physiological action of the 
tear passage. For two or three days after the little opera- 
tion, it is necessary to pass a probe along the portion of 
the canaliculus which has been slit up, to prevent union 
taking place. 

Obstruction of the Canaliculus. — The canaliculus may 
be diminished in its caliber, or entirely closed, by contrac- 
tion the result of inflammation which had extended to it 
from the conjunctival sac. It is not possible to diagnose 
the presence of either of these conditions, which may be 
associated with stenosis or occlusion of the punctum 
lacrimale, except by the introduction of a very fine probe 
into the canaliculus. The passage may also be obstructed 
by an eyelash, a chalky deposit, or a mass of leptothrix. 

The diagnosis of leptothrix in the inferior canaliculus is 
made by the following signs and symptoms : Lacrimation ; 
the presence of a creamy-yellow discharge at the inner 
canthus, without dacryocystitis ; congestion of the caruncle 
and neighboring parts of the conjunctiva. On everting 
the inner end of the lower lid, the region corresponding to 
the canaliculus is seen to be rounded and swollen on its 
conjunctival aspect. The lacrimal punctum is enlarged, 
stands out from the eyeball when the patient looks up, and 
is filled with the creamy exudation. On pressure, a 
hard cylindrical mass can be felt in the canaliculus. At a 
later stage, severe purulent inflammation of the canaliculus 
comes on, with marked swelling of the eyelid in the neigh- 
borhood ; while the greenish-yellow dacryolith contained 
iCx. 90. 1^ ^1^^ canaliculus usually consists of leptothrix or strepto- 
thrix, and actinomyces have also been found. 

Treatment. — Where there is merely diminution in the caliber 



THE LACRIMAL APPARATUS. 235 

of the passage, the introduction of probes, increasing in size, is 
frequently sufficient to effect a cure. If dilatation fail, recourse 
must be had to slitting up the canaliculus ; but, if it can possibly 
be avoided — that is, if a less extended opening will answer — the 
passage should not be slit up in its entire length. At least 3 mm. 
of its median end ought to be left intact, as otherwise regurgita- 
tion of tears from the lacrimal sac is liable to trouble the patient 
ever afterwards. If the canaliculus be completely closed by ad- 
hesions, so that a fine probe cannot be pushed through it, it be- 
comes necessary to rip it up with the point of any small knife, 
following the known course of the passage from the outside. If 
the canaliculus be closed as far as the opening into the sac, or if 
only at that point, the obstruction must be pierced with the pomt 
of a fine knife. A great difficulty in all these cases is to keep the 
passage patent when once formed. A plan which affords toler- 
able certainty of this is the frequent passage of probes into the 
sac until the tendency to closure seems to have ceased ; but even 
under favorable conditions recurrences of the closure are apt to 
occur. 

Leptothrix in the lower canaliculus is readily cured by slitting 
up the passage and evacuating its contents. 

Stricture of the Nasal Duct is usually the result of simple 
swelling of its mucous membrane in a catarrhal attack, which has 
originated in the nasal mucous membrane; or of membranous or 
cicatricial contraction of the mucous membrane resulting from 
long-continued catarrh. It also occurs in consequence of disease 
of the bones of the nose — e. g., in syphilis, acquired or congenital, 
and from blows which fracture the bridge of the nose. 

Treatment. — Stricture due to acute inflammatory swelling of 
the mucous membrane should be treated by the injection of weak 
alum or other astringent solutions into the lacrimal sac, or down 
the nasal duct, by means of an Anel's syringe, and attention should 
be paid to the nasal mucous membrane. Probing here should not 
be attempted, lest it injure the delicate swollen mucous membrane 
of the duct. 

Membranous or cicatricial strictures are best treated by means 
of probes in the manner proposed by Sir William Bowman. The 
inferior canaliculus is slit up to a slight extent so as to admit the 
point of one of Bowman's smallest probes, which is given a curve 
to suit that of the nasal duct. With the fingers of the left hand 
the surgeon stretches the lower lid, and, entering the probe into 



236 DISEASES OF THE EYE. 

the canaliculus, pushes it gently along its floor until the point 
reaches the lacrimal bone forming the posterior wall of the sac. 
The point being kept pressed against this bone, the direction of 
the probe is now altered by carrying its free end upwards towards 
the bridge of the nose until the point in the lacrimal sac is directed 
towards, or aimed at, the sulcus between the ala of the nose and 
the cheek. The probe, then, is in a position corresponding to 
the prolonged axis of the nasal duct, down which it is pushed 
with a slow and gentle motion. Any obstacles met with on the 
way are overcome, if possible, by an increase of the pressure ; but 
if at any part of the proceeding much difficulty be encountered, 
rather than that any violence be used, all further manipulation 
should be postponed to another day, and it will often be found 
that at the second or third visit the probe is passed with compara- 
tive ease. Thicker probes are gradually introduced at successive 
sittings until the largest size has been reached. 

The most common seats for membranous or cicatricial strict- 
ures of the nasal duct are at its entrance into the sac, where it is 
narrowest; and at its lower end, where it is most exposed to 
catarrhal processes spreading from the nostril. 

Where there is reason to think that the stricture is due to 
chronic catarrhal swelling of the lining mucous membrane of the 
duct, astringent injections into the canal, in addition to the prob- 
ing, are of use. 

Otto Becker used very fine probes, which he passed by the 
upper canaliculus. Weber's probes are conical, and of very large 
caliber at the*r thickest part. Their inventor passes them by the 
superior canaliculus, but many other surgeons pass them by the 
lower. I do not employ these probes, because, when passed into 
the nasal duct, their thickest part, which is 3 to 4 mm. in diameter, 
corresponds with the upper end of the duct, which is its narrowest 
part, being only 3 mm. in diameter: consequently the probe be- 
comes more or less impacted at this place at each operation, and 
is apt ultimately to give rise there to hypertrophy of the perios- 
teum, and finally to stricture ; so that, while the immediate effect 
of their use is good, the ultimate result is often the reverse. 
When used by the inferior canaliculus, their size makes it neces- 
sary to slit that passage in its entire length, and the entrance of 
the passage into the sac must be enormously dilated by so large 
an instrument, both of which circumstances are most undesirable. 
Indeed, I entirely agree with those who reject large probes, of 



THE LACRIMAL APPARATUS. 237 

whatever shape or however introduced, in the treatment of lacri- 
mal-duct strictures. 

To prevent closure of the duct when once made free, Arthur 
Benson (DubHn) advocates the use of leaden styles, removable 
by the patient. He first divides the canaliculus (by preference 
the upper one), and dilates the stricture with probes in the ordi- 
nary way, and then introduces into the duct a piece of leaden wire 
1.5 mm. to 2 mm. in diameter, cut to length, and smoothed off at 
the ends. The upper end is curved so as to lie out on the cheek. 
The style is at first removed daily, and the duct syringed, until 
any existing inflammation and discharge have almost ceased. 
The intervals are then increased ; and as soon as practicable the 
patient is taught to remove the style and to replace it himself. 
When he is able to do this easily, he is directed to leave the style 
out for some hours each day, and finally to wear it only at night. 

Stilling has proposed an operation, which he calls strictu- 
rotomy, for the cure of membranous obstructions in the duct. 
Having slit up the canaliculus, and ascertained with a probe the 
position of the stricture. Stilling passes his knife, with the cutting 
edge directed forwards, down the duct and through the stricture ; 
he then withdraws it a little, turns the edge in another direction, 
and pushes it again through the stricture, and performs this 
maneuver a third time before removing the knife. On subsequent 
days large probes are passed. This method has never gained 
much acceptance. 

Very obstinate membranous strictures can sometimes be freed 
by electrolysis. 

The most favorable cases of stricture for cure are those due to 
inflammatory swelling of the mucous membrane, and next in 
order come those caused by membranous or cicatricial contrac- 
tion, while those due to bony obstructions must be regarded as 
incurable. 

Now and then cases of persistent lacrimation will be met with, 
in which the nasal duct and the rest of the lacrimal apparatus are 
in perfect order. These cases are often due to a catarrhal affec- 
tion of the nasal mucous membrane, slightly involving the very 
lowest extremity of the nasal duct. Applications directed towards 
relief of the nasal affection are here indicated. 

Blennorrhea of the Lacrimal Sac, or Chronic Dacryocystitis, 
is commonly caused, in the first instance, by stricture of the nasal 
duct. In consequence of this stricture the tears and the normal 



238 DISEASES OF THE EYE. 

mucous secretion of the lining membrane of the sac are retained, 
and offer favorable conditions for the development of the micro- 
organisms, which are constantly present on the surface of the eye, 
and are carried into the lacrimal sac by the tears. The decompos- 
ing contents of the sac set up inflammation of its mucous mem- 
brane, with discharge of a muco-purulent nature. 

But cases of lacrimal blennorrhea are often met with in which 
no stricture of the nasal duct is found. In many of these cases 
there has been a stricture due merely to catarrhal swelling of the 
lining membrane of the duct, which has subsided in the course of 
time without treatment, and the duct has then again become free, 
while the lacrimal blennorrhea to which the stricture gave rise 
continues. It is very probable, however, that lacrimal blennor- 
rhea may occasionally come on where there has never been a 
stricture of the nasal duct, and merely as an extension of catarrh 
from the nostrils, especially in cases of ozena, or as an extension 
of catarrh from the conjunctiva. 

The patients usually complain of nothing more than epiphora. 
Those who are more observant of themselves may have noticed 
a swelling, which we call a lacrimal tumor or mucocele, in the 
region of the lacrimal sac; and also that the conjunctival sac, 
especially when the swelling is pressed upon, becomes now and 
then more or less filled with a somewhat thick and opaque dis- 
charge, which obscures the sight until wiped away. Occasionally 
there is no lacrimal tumor, for the contents of the sac may not be 
copious enough to distend it markedly. 

In order to ascertain in each case of epiphora whether or not 
lacrimal blennorrhea be present, the surgeon presses with his 
finger over the lacrimal sac, when, if there be blennorrhea, the 
discharge will be evacuated through the puncta into the con- 
junctival sac. In those cases in which there is no longer a strict- 
ure of the nasal duct, the discharge may pass downwards into the 
nose, and the patient will feel it in his nostril, out of which he can 
blow it. 

Conjunctivitis must sometimes be regarded, not as the cause, 
but rather as the effect of a lacrimal blennorrhea, by reason of the 
decomposing discharge from the lacrimal sac making its way 
into the conjunctival sac. Blepharitis, too, is seen as a further 
result of irritation from the discharge in old-standing cases. 

Treatment. — It is important, in the first place, to ascertain 
whether there be a stricture of the nasal duct, and for this purpose 



THE LACRIMAL APPARATUS. 239 

water should be injected by means of an Anel's syringe through 
the canaHcuhis into the duct. If the fluid make its way freely 
into the nose or pharynx, it may be taken for granted that the 
nasal duct is not obstructed ; but if instead of passing through — 
or only under high pressure — it distends the lacrimal tumor to a 
greater size, a stricture may be assumed. If stricture of the nasal 
duct be present, it must be relieved, or all other measures wall 
prove futile. Should there be no stricture, and also before and 
after any existing stricture has been freed, the treatment consists 
in the very frequent pressing out of the contents of the sac by the 
patient, so that no distention of it may occur: and in doing this 
he should endeavor to cause the discharge to pass down the nose 
rather than into the eye ; while the surgeon, having, if necessary, 
dilated the canaliculus, injects astringent solutions into the sac 
daily, to relieve the catarrh. I find that protargol, in a 15 or 20 
per cent, solution, is the best application for introduction into the 
lacrimal sac. The latter should first be washed out with a physio- 
logical salt solution. 

The caustic treatment (recommended further on for acute 
dacryocystitis) is often of the greatest benefit in these chronic 
cases. Any existing conjunctivitis or nasal catarrh should be 
treated. But there are many cases in which no treatment short 
of obliteration or extirpation of the lacrimal sac w^ill bring about 
a radical cure of this very troublesome complaint. 

Obliteration of the sac is desirable in some very chronic cases, 
where repeated attacks of acute inflammation and fistula occur, 
or where there is constant discharge, and disease of bone, or w^hen 
all other methods have failed to relieve the patient. This can be 
done by the application of a galvano-cautery to the lining mem- 
brane of the sac. In my experience, obliteration of the lacrimal 
sac is a most unsatisfactory proceeding. 

Extirpation of the Lacrimal Sac is a preferable proceeding, 
and for it Kuhnt's method ^ is probably the best. 

An incision down to the bone and about 2.5 cm. long is made 
over the anterior lacrimal crest. It begins 4 mm. above the inter- 
nal palpebral ligament, and ends 5 mm. below the commencement 
of the bony lacrimal duct. As a rule the palpebral ligament is 
not divided by this incision, and has now^ to be separated wnth the 
scissors close to its insertion. If there be bleeding from the small 
arteries, they are seized and twisted. The temporal lip of the 
wound is now drawn aside, and the fibrous capsule of the sac 



240 



DISEASES OF THE EYE. 



carefully incised along the crest, care being taken that the sac 
itself is not opened. The anterior wall of the sac, grayish blue 
and shining, then becomes exposed in the cavity. To remove the 
sac the surgeon separates its inner wall from the periosteum with 
the closed blunt ends of the scissors; then the fundus of the sac, 
along with the strong fibrous capsule which is here adherent to it, 
is drawn forwards, and with a few strokes of the scissors is sepa- 
rated from its bed, and the scissors are passed behind the sac 
(Fig. 91), and the posterior wall is similarly separated. The 




Fig. 91. 



temporal lip of the wound is now drawn forwards and outwards 
as much as possible by an assistant, while the surgeon draws the 
fundus of the sac inwards and forwards, and frees the outer and 
what remains attached of the anterior surfaces. Finally, the sac 
is cut off close to the bony canal, and, if there be no close stricture 
present, the mucous membrane of the duct is curetted with a 
sharp spoon. A small drain is inserted and the wound is closed 
by two or three deeply placed sutures, special care being taken to 
secure the palpebral ligament to its insertion. 

Should the sac be opened during the operation, its total extirpa- 



THE LACRIMAL APPARATUS. 241 

tion will be rendered much more difficult ; and if a portion of the 
sac be left behind, the object of the operation is likely to be frus- 
trated by a return of suppuration. If the sac has not been got 
out in its entirety, the suspicious places must be destroyed by 
curetting. There is very often a good deal of troublesome bleed- 
ing during the operation, which must be controlled by compres- 
sion, torsion, and ligation, so that the operation may be carried 
out with the precision upon which its success depends. Where 
there is a fistula of the sac, or where there has been phlegmonous 
dacryocystitis, the operation is rendered much more difficult by 
reason of adhesions. Czermak considers it unnecessary and un- 
desirable to divide the palpebral ligament, because in his opinion 
it is likely to lead to some disfigurement, no matter how carefully 
the sutures may be applied. He finds that the fundus of the sac 
can be got out without division of the ligament. 

The lacrimation, after extirpation of the sac in cases of chronic 
dacryocystitis, is usually less than before. Should it continue to 
any distressing degree, removal of the lacrimal gland is indicated. 

Acute DGcryocystitis (daupvcj^to weep; Hvffri?^ a bladder). 
— Acute inflammation of the lacrimal sac most usually comes on 
when chronic lacrimal blennorrhea is already present. Caries of 
the nasal bones may cause it, and it occurs idiopathically, prob- 
ably as the result of exposure to cold. 

The region of the lacrimal sac and the surrounding integument 
become swollen and red, and these conditions often spread to the 
lids, giving an appearance which is sometimes mistaken for ery- 
sipelas ; but the history of the case, showing the previous existence 
of lacrimal obstruction, etc. will assist the diagnosis. Great pain 
accompanies the inflammatory process. Gradually the region 
corresponding to the lacrimal sac becomes the most prominent 
one of the swelling, and the abscess, pointing there, opens. When 
the pus has been discharged the inflammation subsides, and the 
opening through the skin may either close, the parts resuming 
their normal functions, or the opening may remain as a permanent 
fistula. 

The difiference between chronic blennorrhea of the lacrimal sac 
and acute dacryocystitis, besides the fact that one is a chronic and 
the other an acute inflammatory process, is that the former process 
is confined to the mucous membrane of the sac, while in the latter 
the submucous tissue is involved, with phlegmonous inflammation 
as the result. 



242 DISEASES OF THE EYE. 

Treatment. — In the early stages poultices and purgatives 
should be employed. As soon as palpation of the sac indicates 
the presence of pus it must be evacuated. This can be effected 
either through the canaliculus, by opening it up to its entrance 
into the sac, or by an incision through the integument over the 
sac. The latter is the better method, as it admits of free access 
to the interior of the sac. The next day the walls of the sac are 
to be freely touched with solid mitigated nitrate of silver; or a 
plug of cotton-wool soaked in a strong solution of nitrate of silver 
may be inserted into its cavity, and left there for some hours ; or 
various astringent solutions may be injected into the sac. The 
aim of the treatment, whatever it may be, is to secure a rapid re- 
turn of the mucous membrane to its normal condition. If 
stricture of the nasal duct be present, it must be treated pari 
passu. By these means the discharge from the sac is arrested, 
and the external opening gradually closes. 

If a fistula should form, it may be brought to close, in many 
cases, by simply freeing an existing stricture of the nasal duct; 
or it may be necessary to pare its edges, and bring them together 
by sutures ; or, especially if there be a long fistulous passage, the 
galvano-cautery, in the form of a platinum wire, can be applied 
with advantage. 

Dacryoadenitis(^^Hpi;(i9,/o weep ; ddrfv, a gland) , or Inflam- 
mation of the Lacrimal Gland, occurs in an acute and in a 
chronic form, but is extremely rare in either. I have seen one 
case of acute purulent dacryoadenitis, but no instance of the 
chronic affection. Swelling and hyperemia over the gland and 
of the whole lid, with chemosis of the conjunctiva and much local 
pain, increased on pressure, are the most marked symptoms of 
acute dacryoadenitis. When suppuration has taken place the 
abscess may open into the conjunctiva, as it did in my patient, or 
through the skin. In the latter case it is liable to leave a fistula 
behind it ; and, indeed, the chronic form may also, it is said, lead 
to fistula. 

Numerous cases of chronic enlargement of both lacrimal 
glands have been recorded. Good results have been obtained by 
administration of potassium iodid or mercury in some cases. 

Treatment in the early stages consists in poultices and purga- 
tives. When pus has formed, the abscess may be opened through 
the skin or from the conjunctiva. 

Hypertrophy of the Lacrimal Gland is also of rare occur- 



THE LACRIMAL APPARATUS. 243 

rence. It may attain such dimensions as to push the eyeball out 
of its position. It can only be dealt with by — 

Extirpation of the Lacrimal Gland. — This is performed by 
making an incision through the integument under the outer third 
of the orbital m.argin; the fascia under this is dissected up, the 
gland drawn out with a hook, and dissected out with a scalpel. 
Or, if it be considered sufficient to remove the palpebral portion 
only, this can be done from the conjunctival surface. It can be 
seen in the upper fornix, by separating the lids widely at the outer 
canthus, while the patient looks well down and to the nasal side. 
This partial removal may be performed for persistent lacrimation 
when other means fail. 

Tumors of the Lacrimal Gland. — See chap, xix. 

Reference. 
^ " Ueber die Therapie der Conjunctivitis Granulosa," p. 74. Jena, 1897. 



CHAPTER IX. 
DISEASES OF THE SCLEROTIC. 

Inflammation of the sclerotic is not a common disease, al- 
though the diagnosis " scleritis " is often made by inexperienced 
persons, every redness of the white of the eye being taken for 
inflammation of the sclerotic. Beginners are warned against this 
error. Iritis, cyclitis, and conjunctivitis as well as scleritis, 
cause redness of the white of the eye. 

The diagnosis from conjunctivitis is easily made by observing 
whether the conjunctival vessels can be moved over the affected 
part or not ; while in iritis and cyclitis the ciliary injection is con- 
fined to the part immediately surrounding the cornea. Moreover, 
in iritis the appearance of the iris itself is conclusive; and in 
scleritis, as will just now be seen, the appearances are charac- 
teristic. 

Scleritis attacks only that part of the sclerotic which is an- 
terior to the equator of the eyeball, and is either superficial or 
deep. The superficial form is known as episcleritis. Yet it is 
not always possible to distinguish between these two forms in a 
given case, as the appearances in the early stages are very similar. 
They are probably only different degrees of the same disease. 
But the necessity of admitting the existence of two forms de- 
pends upon the different course they each take ; the superficial 
form being a relatively harmless disease, while the deep form en- 
tails serious consequences. 

Periodic Transient Episcleritis (Fuchs), or Hot Eye (Hutch- 
inson). — This affection has been long known by the name given 
. to it by Mr. Hutchinson,^ and since then it has been described by 
Fuchs - under the title Episcleritis Periodica Fugax. It is char- 
acterized by frequently recurring attacks of inflammation of the 
episcleral connective tissue, giving rise to a vascular injection of 
a violet hue, but without any catarrhal or other secretion, or any 
hard infiltration, as in episcleritis of the usual type. It rarely 
attacks the whole sclerotic at one time, but is commonly confined 
to a quadrant or more, and wanders from one place to another. 

244 



THE SCLEROTIC. 245 

When the attack subsides there is no stain left behind. The at- 
tack may be confined to one eye, or both may be affected, or it 
may go from one eye to the other. Pain, watering of the eye, 
and photophobia are present in varying degrees. Sometimes 
there is swoUing of the eyehds. Occasionally the iris and ciliary 
body become inflamed, and also the retro-bulbar tissue, with 
resulting exophthalmos. The attacks last from one or two days 
to several weeks, and may recur once or twice a year and with 
intervals of only two or three weeks. Patients are usually liable 
to the disease for several years of their life. It attacks adults of 
middle age for the most part. Mr. Hutchinson assigns gout as 
the cause ; but Fuchs has not been able to find any symptoms of 
that diathesis in his patients. Rheumatism and malaria seem 
sometimes to produce it, and in many instances no cause can be 
ascertained. 

Treatment. — The long continuance of most of the cases shows 
that treatment has but little influence over the disease. Quinin 
and salicylate of soda internally are the remedies likely to be of 
most use, with warm fomentations, or the Japanese warmer, and 
a protection bandage locally during an attack. 

Episcleritis appears as a circumscribed purplish, rather than 
red, spot close to, or 2 to 3 mm. removed from, the corneal 
margin. It is often unattended by pain, unless when the eye is 
exposed to irritating causes, and need not be elevated above the 
level of the sclerotic ; but in severe cases there is a decided node at 
the affected place with more or less pronounced pain, which is 
increased on pressure. All the symptoms disappear in the course 
of a few weeks, and reappear at an adjoining place; and in this 
way, in time, the whole circumference of the sclerotic will have 
been attacked. The duration of the affection is usually long ; and 
in those instances where the entire sclerotic becomes affected by 
degrees the process may last for years, on and off. Both eyes are 
often affected. The disease is liable to leave behind it a dusky 
discoloration of the sclerotic where each node was seated, but 
otherwise no harm to the eye ensues. But the patient should be 
made acquainted with the tedious nature of the affection. Very 
mild attacks of episcleritis will be met with, which pass away in 
a few days, and do not recur. 

Cwwses. — The affection is often of gouty or rheumatic origin. 
It occurs sometimes in persons of scrofulous or syphilitic consti- 
tution; and it is more frequent in senior adults than in children 



246 DISEASES OF THE EYE. 

or young people, and more commonly attacks women than 
men. 

Treatment. — No irritant should be applied to the eye. Local 
treatment should be confined to protection with dressing and 
bandages and warm fomentations, and the Japanese warmer is 
very useful. In addition to these, massage should be used, if 
there be not too great tenderness on pressure. Leeching at the 
external canthus is of use when the pain is severe. As regards 
internal remedies, where a syphilitic taint is present, mercury 
should be employed ; if struma, cod-liver oil, maltine, etc. ; or if, 
as is most frequently the case, rheumatism be the source of the 
evil, large doses of salicylate of sodium (say 20 grains four times 
a day) will often be found to act well. Salicylate of lithium is 
recommended in preference to the sodium salt by some. lodid 
of potassium in large doses (20 grains four times a day, or 
oftener) is a useful remedy in some cases of this obstinate disease. 

Deep Scleritis. — Here the whole of that part of the sclerotic 
which forms the front of the eye is more likely to be affected at 
once than in the milder form ; although cases often enough occur 
where only an isolated node is present at a time. 

It is the progress of the case alone which can render the diag- 
nosis between this and the milder forms certain, and hence the 
importance of a guarded prognosis in the early stages of every 
case of scleritis. In the deep form changes — thinning and soft- 
ening — of the scleral tissue take place, which render the latter 
less resistant, and consequently expose it to distention by even 
the normal intra-ocular tension. The result of this is a bulging 
(staphyloma) of the anterior part of the eyeball. This bulging 
in itself produces myopia, and has a deleterious effect upon the 
sight; but at a later period vision is often wholly destroyed by 
secondary glaucoma. It may happen that the thinning, etc., of 
the sclerotic affects only a portion, and not the whole, of its an- 
terior surface; and in such a case the resulting staphyloma will 
be confined to that part of the sclerotic. A staphyloma, whether 
total or partial, presents a bluish-gray appearance, due to the uveal 
tract shining through the thinned sclerotic. 

Either with or without such staphylomatous changes, sclerotiz- 
ing opacity of the cornea may come on, and iritis, chorioiditis, 
and opacity of the vitreous humor are not uncommon complica- 
tions, especially in strumous subjects. Both eyes are usually 
affected. 



THE SCLEROTIC. 247 

Causes. — Young adults are the most common subjects of deep 
scleritis, and it attacks females more often than males. Con- 
genital syphilis, rheumatism, gout, struma, and disturbances of 
menstruation are the most common assignable causes. 

Treatment. — There are few diseases less amenable to treat- 
ment. When any of the above causes can be assumed to be 
present, the suitable remedies are of course indicated. Besides 
this, a bandage when only one eye is affected, warm fomentations, 
or the Japanese warmer, dry cupping on the temple, or the arti- 
ficial leech, complete rest of the eyes, and protection with dark 
glasses are to be recommended. 

When all acute inflammation has passed away, an iridectomy 
is sometimes indicated — either for optical purposes, when the 
pupil is obstructed by corneal opacity, or for the purpose of re- 
ducing glaucomatous tension, or of diminishing a staphyloma. 

Injuries of the Sclerotic. — Ruptures and perforating wounds 
are those which have to be considered. Mere losses of substance 
may be said not to occur. 

The primary danger of a rupture or perforating wound of the 
sclerotic — apart from the loss of the contents of the eyeball, 
which is often associated with it — consists in the possibility of 
infecting organisms being introduced into the interior of the eye, 
and there setting up serious inflammatory reaction. 

Ruptures are caused by blows on the eye, and are often indirect ; 
thus, if the blow be received below the cornea, the rupture takes 
place above the cornea. A common cause of sclerotic ruptures 
amongst the agricultural population is a blow from a cow's horn 
while the animal is being tied up or fed in the byre. The rupture 
is usually from 2 mm. to 5 mm. distant from the corneal margin, 
and runs concentrically with the latter ; and often the conjunctiva 
is not ruptured, but bridges over the opening in the sclerotic. 
Some of the contents of the eyeball may have been forced out 
through the rupture — e g., portions of the uvea, iris, and ciliary 
body, the vitreous, and the lens; and it is sometimes difficult at 
first to ascertain the exact state of affairs by reason of extrav- 
asated blood in the anterior chamber, under the conjunctiva, and 
in the tissues of the eyelids. When the conjunctiva is not rup- 
tured, it is often advisable to confine treatment to the application 
of a bandage, as the covering conjunctiva acts as a protection 
against infection of the wound. Where serious damage has not 
been done to the retina, fair or even good vision may be regained 



248 DISEASES OF THE EYE. 

in many of these cases, which at first sight seem almost hopeless ; 
and should perception of light be present, one may reasonably 
conclude that the retina is not detached. When the lens has been 
dislocated under the conjunctiva, — from whence it can be re- 
moved, after the sclerotic opening has closed, — the patient will of 
course require a glass, as after cataract operation, to give him the 
best vision. 

A large and gaping perforating wound is easily recognized. 
A portion of the chorioid, ciliary body, or iris, according to the 
position of the wound, probably lies in it, or part of the vitreous 
humor may be found in it; while the vitreous humor, as seen 
through the pupil, will be full of blood (hemophthalmos), and 
blood may be present in the anterior chamber (hyphemia, vno, 
under; ai}xa^ blood), especially if the wound be far forwards. 
Small wounds may be concealed by subconjunctival hemorrhage, 
and here reduced tension of the eyeball is sometimes a valuable 
diagnostic sign. 

A clean-cut perforating wound of the sclerotic may heal with- 
out inflammatory reaction, even when portions of the uveal tract 
or vitreous humor are prolapsed into it, these prolapsed parts 
becoming incarcerated in the cicatrix. 

When inflammatory reaction follows upon one of these injuries 
it may either be of the purulent or plastic form. In the former 
case all the contents of the eyeball take part in the suppuration, 
and we term it panophthalmitis, phthisis bulbi being its ultimate 
result. In the plastic form the iris and ciliary body alone are im- 
plicated, and sight is slowly lost ; the eye here, too, becoming 
phthisical. Of the two, the latter process is the more serious, as 
it is prone to give rise to sympathetic ophthalmitis — a danger 
which is not associated with the eye lost through panophthalmitis. 

Where the wound has been produced by a small foreign body, 
which has remained in the interior of the eye, the seriousness of 
the position is much aggravated. This matter will be discussed 
in chap, xiv., on Diseases of the Vitreous Humor. 

Treatment. — In cases where the wound is small (say less than 
3 mm.), no suture need be used: a carefully applied dressing and 
bandage will be sufficient to promote the natural tendency to 
healing. But where the wound is large and gaping, any pro- 
lapsed chorioid, etc., must be freely irrigated with sublimate 
lotion, I in 5000, and completely reduced — or if the prolapsed 
parts, or portion of them, cannot be reduced, they must be abscised 



THE SCLEROTIC. 249 

— ^and the margins of the wound drawn together by a few points 
of fine silk suture passed through part of the thickness of the 
sclerotic; or, the sutures may be passed through the conjunctiva 
at some distance from the edges of the wound, the traction on 
the conjunctiva being often sufficient to close the scleral wound. 
A bandage is applied to each eye, and the patient is confined to 
bed. But, if the injury be such (very gaping wound, much loss 
of contents of the eyeball, or extensive intra-ocular hemorrhage) 
as to render restoration of useful sight, or at least retention of 
the shape of the eyeball, beyond reasonable hope, it is wiser to 
remove the eyeball at once, rather than to run the risk of sympa- 
thetic ophthalmitis without compensating advantage. 

Tumors of the Sclerotic, as primary growths, are exceed- 
ingly rare; but fibroma, sarcoma, and osteoma have been so 
observed. 

Pigment Spots of a yellowish-brown color are often seen in 
the sclerotic close to the corneal margin. They are congenital, 
and of no importance. Occasionally a black pigmented patch 
may be associated with pigmented sarcoma of the ciliary region. 

References. 

^ '' Trans. Ophth. Society, U. K.," v. p. 6. 
^ " Von Graefe's Archiv," xli. 4. p. 229. 



21 



CHAPTER X. 
DISEASES OF THE UVEAL TRACT. 

Inflammations. 

If it be remembered that the iris, ciHary body, and chorioid * 
closely resemble each other histologically, that their blood supply 
is identical, and that they form with each other a continuous 
membrane, it is a matter of surprise to learn that any one of these 
three divisions of the uveal tract can undergo inflammation while 
the other two remain healthy. Yet this is by no means uncom- 
monly the case. But it is, perhaps, more common for at least 
two of them, and especially the iris and ciliary body (irido- 
cyclitis), to be simultaneously inflamed; and the entire uveal tract 
may of course be affected at one time. If all three portions be 
affected, one of them may be much more affected than either of 
the others. Or, commencing in one portion, the inflammatory 
process often spreads to one or both of the other portions. 

Clinically we cannot always know whether only one or more 
than one division of the uveal tract is in a state of inflammation, 
and this uncertainty of diagnosis is particularly liable to arise 
when there is severe acute iritis ; for then the symptoms present 
might all be derived from the iritis alone, while the contracted and 
obscured pupil, the opacity in the aqueous humor and cornea, and 
the irritability of the eye, render impossible a diagnosis of 
chorioiditis by the ophthalmoscope, and the position of the ciliary 
body puts it at all times out of reach of ophthalmoscopic examina- 
tion. It may be taken for granted that in every rather severe 
case of iritis, particularly in those of syphilitic origin, more or less 
cyclitis is also present ; while a deep anterior chamber, tenderness 
on pressure, or punctate deposits on the posterior surface of the 
cornea increase the suspicion. In most cases of slight iritis there 
is probably no cyclitis. 

It is only after the acute inflammatory symptoms have subsided 
and the pupil has become clear that disseminated changes in the 

* ;t<5p«ov, the chorion; hence chorioid, like the chorion. 
250 



THE UVEAL TRACT. 251 

chorioid, opacities in the vitreous humor, and even retinitis and 
optic neuritis, which may lead to optic atrophy, can be discovered, 
with their corresponding depreciation of vision. 

It is convenient, in a systematic consideration of inflammation 
of the uveal tract, to discuss it under the separate headings of 
iritis, cyclitis, and chorioiditis. 

Inflammations of the Iris. — The Signs of Iritis, more or 
less marked, are : 

Discoloration, loss of luster and of distinctness of pattern, and 
functional disturbances (impaired mobility) of the iris, with con- 
traction of the pupil. The loss of luster and of distinctness of 
pattern is due to an alteration in the endothelium, which covers 
the surface of the iris, to the presence of lymph in it and on it, 
and to cloudiness of the aqueous humor through which it is seen, 
caused by inflammatory products held [a suspension; and there 
is often, too, some cloudiness of the cornea. The change in color 
is due to hyperemia of the iris, as well as to the presence of the 
inflammatory products ; a blue iris becomes greenish, a brown iris 
yellowish. The impaired mobility and the contracted pupil are 
due to engorgement of the blood-vessels of the iris, to spasm of 
the sphincter iridis, and to posterior synechia. 

Exudation of inflammatory products is present in greater or 
less degree, and may be found on either surface of the iris, in the 
pupil, in the aqueous humor, on the posterior surface of the 
cornea, and in the tissue of the iris. 

Posterior synechise " — i. e., adhesions between the iris and the 
anterior capsule of the lens — occur as the result of inflammatory 
exudation on the posterior surface or on the pupillary margin of 
the iris. The presence of posterior synechise is ascertained by 
observing the play of the pupil when the eye is placed alternately 
in strong light and in deep shadow, or by observing the effect of a 
drop of atropin solution on the pupil, the latter dilating only at 
those places where there are no synechise. If the entire pupillary 
margin have become adherent, the condition is termed complete 
posterior synechia, circular posterior synechia, ring synechia, or 
exclusion (or seclusion) of the pupil; and in such cases, especially 
if of some standing, atropin has no effect on the pupil. If the 
area of the pupil be filled with exudation, circular synechise being 
usually also present, the condition is known as occlusion of the 
pupil. 

"^^ oivtxi^Lv, to bind together. 



252 DISEASES OF THE EYE. 

Total posterior synechia is that condition in which the whole 
posterior surface of the iris is adherent to the capsule of the lens, 
and is rarely the result of ordinary iritis, but is seen frequently 
in sympathetic ophthalmitis. 

In addition to the foregoing, circumcorneal injection of 
the ciliary vessels is a common symptom in most cases of 
iritis. 

The subjective symptoms in iritis consist, in the first place, of 
pain, due to irritation of the ciliary nerves in the inflamed part. 
Yet this pain is not always referred to the eye itself, but often 
appears in the form of supra-orbital neuralgia, or affects the infra- 
orbital division of the fifth nerve. Dimness of vision is the 
second subjective symptom of iritis. It may be due to cloudiness 
of the aqueous humor, to deposits on the cornea, to exudation of 
lymph on the pupillary area of the anterior capsule of the lens, or, 
where the ciliary body is implicated, to opacities in the vitreous 
humor. 

Cases of iritis in which there has been no pain and no circum- 
corneal injection, and in which the failure of sight alone it is 
which brings the patient to the surgeon, are not uncommon. 
Examination then discovers the presence of extensive posterior 
synechias, which have probably been gradually forming for a long 
time back. These cases of c[uiet iritis are, in my experience, 
usually due to rheumatism (vide infra). 

A mistake into which beginners very often fall is to take a 
case of iritis to be conjunctivitis or scleritis (see pp. 95 and 244), 
the " redness of the white of the eye " being that which misleads. 
The appearance of the iris itself will chiefly assist in the diagnosis. 
Moreover, the pain in iritis is of neuralgic character, but in con- 
junctivitis it is similar to that caused by a foreign body in the 
conjunctival sac. In iritis there is no discharge, while in con- 
junctivitis the eyelids are gummed in the morning by muco- 
purulent secretion. Of course iritis and conjunctivitis may occur 
together. 

Those cases of iritis in which the inflammatory exudation is 
mainly on either surface of the iris and in the pupil are the most 
common. Here the circumcorneal injection is generally well 
marked, sometimes causing elevation of the limbus of the con- 
junctiva, and even general, although slight, chemosis. In very 
mild cases, however, as also in chronic cases, the injection may be 
slight. The loss of luster and of distinctness of pattern of the 



THE UVEAL TRACT. 253 

iris is well marked, and there is considerable change in the color 
of the iris. Posterior synechise are very apt to form. In some 
rare cases of this form of iritis an enormous quantity of gelatinous 
exudation is present in the anterior chamber. In Secondary 
Syphilis one often sees iritis of this kind. 

Rheumatic Iritis, too, is sometimes of this kind, but accom- 
panied by circumcorneal injection, which is great in proportion 
to the other signs of iritis present. The pain in rheumatic iritis is 
often peculiarly severe. Yet, as I have already stated, quiet iritis 
is most often due to rheumatism. 

Gonorrheal Iritis is also of this kind, although with it there is 
often seen the punctate deposit on the posterior surface of the 
cornea. It does not attend on, nor immediately follow, a gonor- 
rhea; but an attack of rheumatic arthritis, usually of the knees, 
always intervenes. Gonorrheal iritis is extremely rare. 

Those cases of iritis which are chiefly characterized by the de- 
posit of fibrinous elements, as very fine pale buff-colored dots on 
the posterior surface of the cornea, with more or less turbidity of 
the aqueous and some tendency to the formation of posterior 
synechi?e, used to be, and very often are still, although errone- 
ously, called cases of Serous Iritis, while the fine dotted appear- 
ance on the back of the cornea was commonly known as '' kera- 
titis punctata," a term for which " unctate corneal deposits " 
should be substituted. We know now that the inflammatory 
product is fibrinous and not serous, and that in these cases the 
ciliary body may be quite as much, if not more, affected than the 
iris, and hence that these are to be regarded as cases of irido- 
cyclitis of a sluggish or chronic form. The fibrin passes from 
the ciliary body into the aqueous humor, and from it is precipi- 
tated as fine buff-colored or pale yellowish dots on the cornea in 
its lower quadrant by force of gravity. The part of the cornea 
which is thus affected is often of a triangular shape, the base of 
the triangle corresponding with the lower margin of the cornea, 
the apex being directed towards the center of the cornea, with the 
finer dot near the apex. The triangular shape is a mechanical 
result of the motions of the eyeball. In many cases, however, 
nearly the whole cornea is more or less affected. 

In cases where the punctate corneal deposits continue for a 
length of time, in consequence of the resulting degeneration of 
the posterior epithelium, permanent secondary changes in the 
true cornea take place, and a consequent pecuHar triangular 



254 DISEASES OF THE EYE. 

opacity at the lower part of the cornea will ever afterward in- 
dicate the nature of the process which has begun before. 

In this form of iritis the circumcorneal injection is slight, the 
anterior chamber is often deep, and the aqueous humor is some- 
times cloudy. The intra-ocular tension is frequently increased, 
from the presence of exudation in the angle of the anterior 
chamber. 

Where the inflammatory product is situated in the tissue of 
the iris, the consequent swelling may be present over its whole 
extent, or may be confined to a circumscribed part of it. In the 
latter case the swelling is sometimes called a condyloma. The 
color of the iris changes remarkably at the affected part to a yel- 
lowish or reddish-yellow hue, and new vessels are formed in it. 

In Syphilis, late in the secondary stage, a form of iritis occurs 
which may be always recognized as syphilitic. It is characterized 
by the formation of circumscribed tumors or small condylomata 
of a yellowish color, the rest of the iris being apparently intact. 
These tumors vary in size from that of a hemp-seed to that of a 
small pea, and are situated usually at the pupillary margin, occa- 
sionally at the periphery of the iris, and very rarely in the body 
of the iris. There may be but one tumor present, and there are 
seldom more than three or four. This form is not common. But 
many authors hold that in most, if not in all, cases of syphilitic 
iritis condylomatous tumors are present, though of such small 
size as to escape detection with our ordinary clinical methods. 

Hemorrhagic iritis is not a special form of iritis, but is merely 
a severe inflammation of the iris with hyphemia. It is chiefly 
seen in iritis due to operations and injuries, in some cases of sym- 
pathetic iritis, and in old people. 

Symptoms of Iritis in General. — (i) Pain. This is situated 
not so much in the eye as in the brow over it, in the correspond- 
ing side of the nose, and in the malar bone, and may even extend 
to the whole side of the head. It varies in its intensity ; it is usu- 
ally more severe at night, and is often called neuralgia by the 
patients. That form of iritis with exudation on the surface of 
the iris and in the pupil is the one attended by the most severe 
pain; the form with punctate deposits on the posterior surface 
of the cornea as its main characteristic is generally unattended 
by pain ; while the form with marked circumscribed deposits or 
condylomata in the stroma of the iris is in many cases excessively 
painful and in some completely painless. (2) Lacrimation and 



THE UVEAL TIL\CT. 255 

photophobia are occasionally present, but never to such a degree 
as is often observed in some corneal affections. (3) Dimness of 
vision. This is usually complained of as soon as the inflamma- 
tion is pronounced. Cloudiness of the aqueous humor and punc- 
tate corneal deposits affect sight in proportion to their degree ; 
and exudation in the pupil may reduce vision to a quantitative 
amount. 

The tension of the eye in iritis is usually normal, but in some 
violent cases it will be found to be high, as also in some cases 
where, while the inflammatory symptoms are but slight, the punc- 
tate corneal deposits are marked, and in cases, too, where the 
angle of the anterior chamber is blocked. 

Prognosis. — The length of duration of an attack of iritis can- 
not be foretold at the outset. Cases which are in other respects 
mild — i. e., where the pupil dilates well and rapidly to atropin, 
where the aqueous humor is clear, and where but little lymph is 
thrown out — often continue for weeks irritable and painful, with 
a marked tendency to relapse if treatment be at all relaxed. An 
attack of iritis may last from two to eight weeks. Recurrences 
of the inflammation are common, owing to continuance of the 
constitutional taint, which gave rise to the iritis in the first 
instance. 

It is possible that an attack of any form of iritis, if carefully 
treated from the beginning, may leave the eye in as healthy a 
condition as before ; but it is quite as common, in spite of every 
effort, to find posterior synechias, isolated or as a circular synechia, 
left behind. 

The presence of a few isolated synechiae, if the pupil be clear, 
is in itself harmless to sight ; but if relapses take place and fresh 
adhesions be formed, a complete posterior synechia may ulti- 
mately be established. When this occurs, the aqueous humor 
being still secreted behind the iris, and being unable to escape 
into the anterior part of the chamber, the iris becomes bulged for- 
ward, like the sail of a ship, until it touches the peripheral part 
of the cornea : while the center of the anterior chamber retains its 
normal depth. This condition is very liable to induce glauco- 
matous tension (secondary glaucoma) and consequent loss of 
vision : or. if the eye escape this danger, chronic inflammation of 
the ciliar}^ body and chorioid — so-called chronic irido-cyclitis, or 
irido-chorioiditis — may develop, and may lead to diminished ten- 
sion and phthisis bulbi, with detachment of the retina and calcifi- 



256 DISEASES OF THE EYE. 

cation of the lens ; or, the eye having been first bhnded by high 
tension, may at a later period undergo phthisis bulbi. 

Complete posterior synechia may of course result from the first 
and only attack of iritis, and not by means of repeated relapses. 

In some cases of iritis the vitreous humor becomes more or 
less opaque, and this condition does not always disappear as the 
iritis gets well ; indeed, it may not be possible to ascertain its pres- 
ence until after the inflammatory process in the iris has subsided. 
Very great and permanent deterioration of vision may result in 
such instances ; and they emphasize the importance of a cautious 
prognosis at the commencement. It is probable that in these 
cases the ciliary body participates in the inflammation, and is 
mainly responsible for the opacities in the vitreous. 

Causes. — Iritis is not common in children, except as complicat- 
ing a corneal process, or as a result of congenital syphilis or 
tuberculosis (see New Growths of the Iris, p. 289). Towards 
puberty slight iritis is sometimes found in girls. Youth and 
middle age are the times of life in which iritis is most often seen, 
while in old age it again becomes rare. 

More than 50 per cent, of the cases depend on syphilis, and a 
large proportion of the remainder are due to rheumatism. Dur- 
ing desquamation after smallpox iritis is sometimes observed. 
In metria and septicemia purulent iritis occurs, as also with 
typhoid fever, pneumonia, and recurrent fever. Diabetes some- 
times causes iritis. 

TreaUnent. — A mydriatic (see table, p. 316), is, above all 
others, the most important means. Most commonly a solution 
of atropin is used (Atrop. sulph. gr. iv, Aq. dest. §j) as drops. 
An atom of sulphate of atropin in substance, placed in the con- 
junctival sac, gives a very active reaction. It is also used in the 
form of an ointment (Atrop. sulph. gr. iv, vaselin oJ)j and gela- 
tin discs containing atropin are manufactured. By paralyzing 
the sphincter iridis atropin provides rest for the inflamed iris ; 
and if adhesions have already formed, the dilatation of the pupil 
may break them down, while if none are as yet present, the dila- 
tation will greatly aid in preventing their formation. To pro- 
duce a maximum effect, where it is desired to break down adhe- 
sions, six drops of the atropin solution should be instilled into the 
eye, with an interval of from five to ten minutes between each; 
and in this way the atropin from each drop has time to make its 
way into the anterior chamber, and finally the accumulated effect 



THE UVEAL TRACT. 257 

of all six is obtained. More than one drop can hardly be retained 
in the conjunctival sac at a time. The use of cocain (2 per cent.) 
along with atropin insures a maximum dilatation. A drop in the 
eye from twice to four times a day is required, in order to main- 
tain the desired dilatation of the pupil ad uiaxUmim. 

Some individuals are peculiarly susceptible to Atropin Poison- 
ing, of which the symptoms are dryness of the throat, fever, full- 
ness in the head, headache, delirium, coma. The antidote is 
morphia, of which 1-4 grain used hypodermically neutralizes 1-30 
grain of atropin in the system. Atropin poisoning can occur by 
the introduction of the solution into the stomach through the 
lacrimal canaliculi, nose, and fauces ; and to prevent this the fin- 
ger (of the patient) may be placed in the inner canthus, so as to 
occlude both canaliculi during, and for some moments after, the 
introduction of the drop into the eye. 

After long use of atropin the skin of the lower eyelid, or of 
both eyelids, often becomes eczematous, red, swollen, and painful, 
from infiltration with the drug ; and in other cases follicular con- 
junctivitis is induced. If these complications occur, sol. extr. 
belladonna (gr. viij ad %]) should be substituted for atropin, 
and suitable remedies used for skin or conjunctiva. 

In old people tenesmus and retention of urine sometimes result 
for use of atropin. 

Atropin, while it is so useful a means in the treatment of in- 
flammations of the iris, ciliary body, and cornea, is of no benefit 
in many other diseases of the eye, and is positively harmful in 
some of them. It is necessary to make this statement very ex- 
plicitly, for some — perhaps I should say many — medical men who 
have not devoted attention to the subject of eye-disease include 
atropin in every eye-lotion they prescribe. If the disease pre- 
scribed for be conjunctivitis, as it very often is, the atropin is cal- 
culated rather to increase than to relieve the conjunctival affec- 
tion ; while, if the patient be advanced in Hfe, there is always the 
danger that a tendency to glaucoma may be present, and in such 
a case the dilatation of the pupil caused by the atropin will be 
sufficient to bring on an attack of acute glaucoma. In these days 
it falls to the lot of most ophthalmic surgeons to be called, at one 
time or another, to a case of acute glaucoma brought on by the 
gratuitous use of atropin in this manner. It is to be feared that 
the reason for this random prescribing of atropin is to be found 
in an ignorance of diagnosis, which leads practitioners to throw 

22 



258 DISEASES OF THE EYE. 

atropin with a number of other drugs into their eye-lotions in the 
hope that some of the ammunition will hit the mark, wherever 
the latter may be. 

Dark protection spectacles should be worn by patients suffering 
from iritis; and in severe cases, especially in cold weather, a 
bandage should be worn, and the patients should be confined to 
a dark room, and even to bed. 

In that form of iritis where the inflammatory exudation is 
mainly on the surface of the iris and in the pupil, iodid of potas- 
sium or perchlorid of mercury may be given internally. If there 
be much irritation, pericorneal injection, or chemosis, leeching at 
the external canthus is of use. Intermittent warm fomentations 
(every two hours) promote healthy vascular reaction. Pain is 
to be relieved by hypodermic injections of morphia, and by chloral 
internally. 

In rheumatic iritis and in iritis due to diabetes, salicylate of 
sodium in large doses (20 to 30 grains every three hours) has 
often a remarkably favorable effect. 

In many of those cases in which punctate deposits on the 
cornea are the chief characteristic a small quantity of atropin will 
suffice, as there is often but little tendency to the formation of 
synechiae, and, the irritation being slight, leeching is unnecessary. 
The skin (Turkish baths and dry rubbing), kidneys, and bowels 
should be acted on; and to the diuretics prescribed some iodid 
of potassium may be added. Turpentine in 5j doses, as recom- 
mended by Carmichael, of Dublin, is often a useful remedy 
here. 

Blistering on the temples or behind the ears is with many sur- 
geons a favorite remedy. It adds to the annoyance of the patient, 
but as a remedy in this, or, indeed, in any other eye disease it is 
useless. 

Great care is required in watching the tension of the eye in this 
form of iritis , and, if it be found to increase and to remain high 
for three or four days, paracentesis of the anterior chamber must 
be performed to reduce it temporarily while the iritis is still pro- 
gressing towards cure. This little operation is exceedingly use- 
ful if there be much deposit on the posterior surface of the cornea, 
as by means of it the deposit, to a great extent, may be floated 
away. Indeed, in many cases of punctate corneal deposits, re- 
peated tapping of the anterior chamber is a valuable curative 
measure. It should be performed, say, on three successive days, 



THE UVEAL TRACT. 259 

and similarly again after an interval of four or five days, and so 
on, according as the condition of the eye permits. (For mode of 
performing paracentesis, see p. 147.) 

Where the exudation is in the form of circumscribed tumors or 
condylomata in the stroma of the iris, it is important to obtain 
rapid absorption of the inflammatory products, which are so 
abundantly thrown out, and which, in an organ like the eye, would 
soon cause extensive destruction. Consequently, the system 
should be put under the influence of mercury as quickly as pos- 
sible, by the use of inunctions of mercurial ointment or by small 
doses of calomel internally; and this treatment is indicated, even 
when the inflammation is not of syphilitic origin. Warm fomen- 
tations are useful. An after-treatment with iodid of potassium is 
to be employed. 

In Syphilitic Iritis von Graefe gave the following: 

I^ Hydrarg. biniodid. gr. vj ; Potass, iodidi, 3 iss. ; Aq. destill. 1 ss. 
Syr. Auraiii. 3 iiss. M. A teaspoonful to be taken once a day. The dose 
to be gradually increased. 

In Purulent Iritis quinin and salicylate of sodium are the most 
suitable internal remedies. 

Inflammation of the Ciliary Body ; Cyclitis. — Cyclitis, as al- 
ready stated, is often present with inflammatory affections of the 
iris or chorioid, although its presence in many of these cases can- 
not be clinically determined ; but primary idiopathic cyclitis is 
rare. 

The Symptoms of Cyclitis, although not always all of them 
present, consist in marked circumcorneal injection, ciliary neu- 
ralgia, pain on pressure of the ciliary region, deep anterior cham- 
ber, opacity in the anterior part of the vitreous humor, punctate 
deposits on the posterior surface of the cornea, and sometimes 
hypopyon in the anterior chamber. Edema of the margin of the 
upper lid is also frequently present. 

There are three forms of cyclitis : 

In the first the circumcorneal injection is but slight. The 
anterior chamber is often at first deeper than normal, owing to 
hypersecretion of aqueous humor from the ciliary body ; there are 
punctate opacities on the posterior surface of the cornea ; and the 
anterior part of the vitreous humor is filled with fine dust-like 
opacities. Iritis may come on, and the danger of glaucomatous 
increase of tension is great, owing to the tendency to blocking of 



26o DISEASES OF THE EYE. 

the anterior chamber with inflammatory exudation. Unless in- 
crease of tension gives rise to it, pain is not often present. Pri- 
mary idiopathic cycUtis is usually of this form. 

In the second form there is much plastic exudation, the cir- 
cumcorneal injection is very marked, and there is venous conges- 
tion of the iris. The anterior chamber is deep, owing to retrac- 
tion of the periphery of the iris by inflammatory exudation in the 
ciliary body, and owing to this retraction, too, the pupil is dilated. 
The inflammation may extend to the iris or to the chorioid, and in 
the latter case the vitreoiis may become very opaque. Violent 
ciliary pains attend the affection, and the eyeball is very tender on 
pressure of the ciliary region. The intra-ocular tension is 
reduced. 

In purulent cyclitis, which is the third form, the circumcorneal 
injection is very well marked. The vitreous humor is filled with 
membranous opacities. There is hypopyon in the anterior 
chamber, which has the characteristic of appearing and disap- 
pearing at intervals of a few days. There is severe ciliary neu- 
ralgia ; and purulent iritis, or chorioiditis, or both, are apt to 
supervene. 

Prognosis. — In an early stage all these forms are capable of 
undergoing cure and of leaving the eye in a fairly useful condi- 
tion. On the other hand, the first form, as already stated, is 
liable to produce secondary glaucoma; the purulent form leads 
to atrophy of the iris and chorioid, disorganization of the vitreous 
humor, detachment of the retina, cataract, and phthisis bulbi ; and 
the form with much fibrinous exudation, when it is due to a per- 
forating injury, in addition to serious damage to the affected eye, 
similar to that produced by purulent cyclitis, has the tendency to 
cause sympathetic uveitis of the other eye. The shrunken eyes 
resulting from the affection are often very liable to fresh attacks 
of inflammation, and frequently remain painful to the touch, cir- 
cumstances which indicate that chronic cyclitis is still present, 
and, when the original cause of the inflammation has been a per- 
forating injury, these stum.ps are a constant source of danger to 
the sound eye from sympathetic ophthalmitis. 

Causes. — Traumata are the most common causes of the aft'ec- 
tion. Both the fibrinous and the purulent forms are liable to 
occur after cataract operations, as the result of infection of the 
wound, but this has now become very rare, owing to the careful 
aseptic measures employed. 



THE UVEAL TRACT. 261 

The Treatment for cyclitis is similar to that for iritis. Leech- 
ing at the outer canthits is often of great benefit. 

Inflammations of the Chorioid. — There are two great forms of 
inflammation of the chorioid (xopzoF,//i(? chorion; hence chorioid, 
like the chorion), the exudative and the purulent. Of the exu- 
dative form, again, there are several kinds, namely, disseminated 
chorioiditis, central chorioiditis, central senile chorioiditis, gut- 
tate chorioiditis, and syphilitic chorio-retinitis. 

Disseminated or Exudative Chorioiditis. — The usual Ophthal- 
moscopic Appearances of this disease consist either in round 
white spots of different sizes with irregular black margins, or in 
small spots of pigment, these changes being surrounded by healthy 
chorioidal tissue ; or there may be few or no white patches, but 
rather spots of pigment surrounded by a pale margin. The 
retinal vessels pass over, not under, the patches. The number of 
these patches or spots varies according to the intensity of the dis- 
ease. Their position is at first at the periphery of the fundus 
only, but later on they appear also about the posterior pole of the 
eye. 

These appearances represent a rather late stage of the disease, 
the early stage not usually coming under observation. It con- 
sists in small circumscribed plastic exudations into the tissue of 
the chorioid, which, seen with the ophthalmoscope, give the ap- 
pearance of pale pinkish-yellow spots. The exudations may 
undergo absorption, leaving the chorioid in a fairly healthy state ; 
but more usually they give rise to atrophic cicatrices, in which the 
retina becomes adherent, with proliferation of the pigment- 
epithelium layer in their neighborhood, and hence the white 
patches with black margins above described. This is the form of 
chorioiditis which is often associated with the inflammatory 
processes in the iris or ciliary body, either as a primary or second- 
ary affection. But, again, in many instances the disease does 
not extend beyond the chorioid. 

Sometimes, in addition to the above changes, the pigment- 
epithelium layer all over the fundus becomes atrophied, exposing 
to view the vascular network of the chorioid, while here and there 
small islands of pigment are present. 

Opacities in the vitreous humor are sometimes found. 

Symptoms. — Diminution in the visual acuity, especially if the 
macula be involved; there may also be subjective sensations of 
Hght or colors, positive scotoma (a dark area visible to the 



262 DISEASES OF THE EYE. 

patient), and distortion of objects (metamorphopsia), or altera- 
tion in their size (megalopsia and micropsia). Night-blindness 
is not uncommon. 

Causes. — Disseminated chorioiditis is due to acquired syphilis 
in a considerable number of the cases, and possibly in some it may 
be tubercular. But in a very large proportion of cases no ascer- 
tainable cause exists ; and those, there is reason to suspect, are 
congenital, and probably many of them are dependent on an 
inherited syphilitic taint. In eyes with congenital cataract, patches 
of chorioiditis are often found. 

Prognosis. — Disseminated chorioiditis is always a serious dis- 
ease, and complete recovery cannot be looked for. The de- 
gree of defect of sight it may cause depends much on the 
extent to which the region of the macula lutea has become in- 
volved. 

Treatment. — In fresh cases due to acquired syphilis a pro- 
longed, but mild, course of mercurial inunctions is the most suit- 
able measure, to be followed by a lengthened course of treatment 
with iodid of potassium. Where an inherited syphilitic taint is 
suspected, iodid of iron or iodid of potassium internally may be of 
use ; while, in the cases due to other causes, small doses of per- 
chlorid of mercury may be given ; and in all cases, from what- 
ever cause, dry cupping on the temple, or even the artificial leech, 
should be employed. Dark protection spectacles should be worn, 
and absolute rest of the eyes from all near work insisted upon so 
long as the disease is active. Subconjunctival injections of 4 per 
cent, of common salt are also used in these cases, and I find this 
method very useful. 

Syphilitic Chorioido-Retinitis. — See Syphilitic Retinitis, chap. 

XV. 

Central Senile Guttate Chorioiditis. — Under this name an ap- 
pearance has been described by Mr. Waren Tay and others which 
consists of fine white, pale yellow, or glistening dots, best seen in 
the upright image, and situated chiefly about the macula lutea, 
or between this and the optic papilla. These dots are due to 
colloid degeneration with chalky formations in the vitreous layer 
of the chorioid, which give rise to secondary retinal changes. 
The appearances must not be confounded, as they sometimes 
have been, with those of retinitis punctata albescens (chap, xv.), 
which is an entirely different disease. The functions of the 
retina usuallv suffer in a marked manner, so that a partial central 



THE UVEAL TRACT. 263 

scotoma may be produced ; but some cases have been observed in 
which vision was but little, or not at all, affected. 

This disease attacks both eyes, either simultaneously or with 
an interval, and is most often seen in persons of advanced life, 
although also found in middle age, and even in youth. It should 
always be looked for in cases of incipient cataract ; for when the 
lental opacity is more advanced it cannot be seen, while functional 
examination does not then detect it. 

Treatment is of no avail. 

Central Chorioiditis. — This is an exudation at the macula lutea, 
without any similar disease elsewhere in the fundus. Absolute 
central scotoma is its prominent symptom, and syphilis its usual 
cause. 

Treatment. — Active mercurialization ; and where this can be 
adopted early the prognosis for recovery of sight is fair. 

Purulent Chorioiditis. — This consists at first in a purulent 
extravasation betw^een the chorioid and retina, and into the vitre- 
ous humor, recognizable by the yellowish reflection obtained 
from the interior of the eye on illuminating it. The eyeball may 
become hard, the pupil dilated, and the anterior chamber shallow. 
Purulent iritis with hypopyon- soon comes on, and the cornea 
may also become infiltrated and slough away. There is usually 
considerable chemosis. The eyeball is pushed forwards by in- 
flammatory edema of the orbital connective tissue. The eyelids 
are sw^ollen and congested. There is intense pulsating pain in 
the eye, and radiating pains through the head ; and in this stage 
?.ll the tissues of the eyeball are engaged in the purulent inflam- 
mation, and the condition is termed Panophthalmitis. 

Purulent chorioiditis does not always reach this latter stage, 
but may remain confined chiefly to the chorioid, vitreous humor, 
and iris. The pain in such cases is not severe ; and when the 
afi'ection occurs in children it may be mistaken for glioma; in- 
deed, the name pseudo-glioma has, unfortunately, been given to 
it. It is distinguished from the malignant disease by the muddy 
vitreous usually present wdth it, by the posterior synechise, and 
by the retraction of the periphery of the iris, with bulging for- 
w^ards of its pupillary part. 

Prognosis. — The ultimate result in the vast majority of cases 
is loss of sight, with phthisis bulbi. The severe cases g"o on to 
bursting of the eyeball through the cornea or sclerotic, after 
which the pain subsides. It would seem from the description of 



264 DISEASES OF THE EYE. 

authors who have seen much of epidemic cerebro-spinal menin- 
gitis, that a certain number of cases of irido-chorioiditis occur- 
ring in the course of that disease do recover with retention of 
good sight. 

The shrunken eyeballs produced by panophthalmitis are not 
generally painful on pressure, and it is remarkable that they are 
not very liable to give rise to sympathetic ophthalmitis, which 
latter observation is also true of the acute purulent process itself. 
It is traumatic cases of plastic irido-chorioiditis which produce 
sympathetic ophthalmitis. 

Causes. — The most common causes of purulent chorioiditis are 
wounds of the eyeball, whether accidental or operative ; foreign 
bodies piercing and lodging in the eyeball ; and purulent keratitis. 
It may also come on suddenly in eyes which are the subjects of 
incarceration of the iris in a corneal cicatrix through infection 
of the incarcerated iris. 

It is seen as embolic or metastatic chorioiditis, in connection 
both with epidemic and sporadic cerebro-spinal meningitis (chap, 
xix.) ; in some cases of metria, similarly as purulent retinitis 
(chap. XV.) ; in pyemia of the ordinary type; and in endocarditis. 

In infancy and childhood, besides its occurrence with cerebro- 
spinal meningitis, it has been known to be caused by, or asso- 
ciated with, inherited syphilis, measles, bronchitis, diarrhea, 
whooping-cough, and omphalo-phlebitis ; and it is more than 
probable that in every idiopathic case some infective blood-disease 
is the fundamental cause of the process, although it may not al- 
ways be possible to determine its existence. 

Treatment may be said to be powerless in this disease. The 
utmost one can do is to endeavor to diminish the pain in the 
very severe cases by warm fomentations, poultices containing 
powdered conium leaves, hypodermic injections of morphium, 
or, finally, by giving exit to the pus by a free incision in the eye- 
ball, followed by a copious irrigation with weak sublimate lotion, 
so as to wash out the whole contents of the scleral cavity. 
Quinin and chlorate of potash are suitable internal remedies. 

I agree with those who think that enucleation of the eyeball 
should not be undertaken during purulent chorioiditis in the 
acute stage, as it is liable to lead to purulent meningitis and death ; 
but some surgeons do not recognize any such danger, and prac- 
tice enucleation in this condition. 



THE UVEAL TRACT. 265 



Sympathetic Ophthalmitis, and Sympathetic 
Irritation. 

Introduictory. — By Sympathetic Ophthalmitis we understand 
a general plastic uveitis (plastic inflammation of iris, ciliary 
body, and chorioid) of one eye, which has been caused by a plas- 
tic uveitis of the other eye, the latter condition being due to a 
perforating trauma, or other perforation of the eyeball. Or, the 
sympathetic ophthalmitis occasionally consists in an optic neu- 
ritis. That sympathetic ophthalmitis can be caused without a 
perforation of the coats of the first eye is exceedingly unlikely. 

There are no such diseases as sympathetic cataract, conjunc- 
tivitis, detachment of the retina, keratitis, scleritis, etc. 

The term " sympathetic " in this connection is an old one, and, 
we may safely say, would not be employed had the disease to be 
named at the present time. It has indeed been proposed to sub- 
stitute the title Ophthalmia Migratoria, but, although preferable, 
as indicating the prevailing theory of the causation of the disease, 
it has not come into general use, and the old name will probably 
always remain the current one. Nor is it a matter of importance 
what the name may be, save in so far as it may give an erroneous 
impression concerning the nature of the disease. 

It is well, therefore, to state at once that sympathetic ophthal- 
mitis is not a fifth-nerve reflex phenomenon. It is a uveitis, and 
often also an optic neuritis, which, according to the generally ac- 
cepted theory, has arisen by direct transmission or migration of 
bacteria, by way of the optic nerves and optic commissure, from 
the injured eye, in which uveitis has been set up, to the sym- 
pathizing eye. No sympathetic uveitis can be developed in the 
second eye until after uveitis in the first eye has commenced. A 
perforating injury of the eyeball, or other perforation, which 
does not produce uveitis in that eye, does not give rise to sym- 
pathetic ophthalmitis in the fellow eye. Traumatic uveitis in the 
injured eye does not cause sympathetic ophthalmitis in every 
case. 

But while sympathetic ophthalmitis is not a reflex condition, 
there is an affection known as sympathetic irritation, which is a 
true fifth-nerve reflex neurosis ; and the two affections, although 
sometimes closely associated clinically, are quite distinct from 
each other. 



266 DISEASES OF THE EYE. 

We speak of the eye that has received the perforating injury 
as the exciting eye, and its fellow, which becomes the subject of 
sympathetic ophthalmitis, as the sympathizing eye. The eyes 
are also spoken of as the injured eye and the sympathizing eye; 
also as the first eye and the second eye. 

Before treating of sympathetic ophthalmitis, it will be con- 
venient to state what is necessary concerning sympathetic 
irritation. 

Sympathetic Irritation. ' 

This may be caused by almost anything which produces irri- 
tability of the ciliary nerves in the first eye — e. g., foreign bodies 
on the cornea or under the upper lid, losses of substance of the 
corneal epithelium, anterior staphyloma, acute glaucoma, iritis, 
dislocation of the crystalline lens, etc., etc. Amongst the causes 
of sympathetic irritation is an irritable shrunken globe, whether 
the latter condition be the result of a uveitis from a perforating 
injury, or of an idiopathic uveitis ; and a shrunken globe may 
rise to sympathetic irritation at any time, even after many years. 
Having remained quiet for so long, the shrunken eye begins to 
lacrimate, and becomes painful and injected. A fresh injury to 
the stump may be the cause of this, or it may be ossification of its 
chorioid, and the irritation, whatever its cause, may be trans- 
mitted to the sound eye. 

The most common symptoms of sympathetic irritation are : 
photophobia, lacrimation, vascular injection of the front of the 
eyeball, and accommodative asthenopia, and, in a well-marked 
case, these symptoms may become intensely distressing to the 
patient. Neuralgia in the orbit and brow, and retinal asthenopia, 
sometimes occur. Amblyopia has also been recorded, but the 
existence of a sympathetic amblyopia has not, I think, as yet been 
satisfactorily established. 

Now we know {vide infra) that sympathetic ophthalmitis, too, 
is often caused by a shrunken fellow eyeball in which uveitis, in- 
dicated by the presence of irritability, is present ; and of great 
interest and importance is the question : What relation, if any, 
has sympathetic irritation to sympathetic ophthalmitis in such 
cases? Is sympathetic irritation to be regarded as a reliable and 
essential premonitory symptom of sympathetic ophthalmitis? 
The answer is in the negative. Sympathetic irritation may last 
an indefinitely long time without being followed by sympathetic 



THE UVEAL TRACT. 267 

ophthalmitis. Further, although some sign or signs of sympa- 
thetic irritation often do precede the onset of sympathetic oph- 
thalmitis, yet in many cases every such sign is wanting. It is, 
therefore, wrong to postpone a prophylactic enucleation until 
sympathetic irritation shows itself. 

Treatment. — When sympathetic irritation is caused by an 
irritable shrunken globe on the opposite side, it can be imme- 
diately relieved by removal of the stump. The employment of 
rest in a dark room and sedative measures, while they may seem 
to cure, merely lead to disappointment, owing to the almost cer- 
tain return of the symptoms, when the eye is brought into use 
again. Moreover, as sympathetic irritation does often precede 
sympathetic inflammation, it is wise to enucleate the exciting 
stump in order to assure the safety of the second eye. 

Sympathetic Ophthalmitis. 

Diagnosis. — The inflammation of the uveal tract in the sym- 
pathizing eye has no characteristics which enable us to make the 
diagnosis " Sympathetic Ophthalmitis," for precisely the same 
plastic or sero-plastic uveitis, as the case may be, is seen under 
other conditions ; nor is the state of the first eye, taken alone, a 
certain guide. To arrive at a diagnosis it is necessary to weigh 
different circumstances, and to take them collectively into con- 
sideration — namely : 

1. The condition of the exciting eye, and the nature of the in- 
jury to, or disease of, that eye. 

2. The condition of the sympathizing eye. 

3. The interval that has elapsed between the injury to the ex- 
citing eye, and the onset of the uveitis in the sympathizing eye. 

4. The state of the general system. 

I. The Condition of the Exciting Eye. — As already stated, 
perforating injuries, or perforating corneal ulcers, of the first or 
exciting eye, which are followed by plastic uveitis, are by far the 
most common, if not the only, causes of sympathetic ophthalmitis. 
If no inflammation follows the injury, there will be no sympa- 
thetic ophthalmitis, even though the wound be a large one. Nor 
has the position of the wound in the eye any influence in the pro- 
duction of sympathetic ophthalmitis. If uveitis comes on in the 
injured eye, it is due to infection of the wound by bacteria derived, 
most usually, w^e believe, from the foreign body or instrument 



268 DISEASES OF THE EYE. 

which has caused the wound, but possibly from the surface of the 
eye, or from the atmosphere. 

Either a purulent uveitis or a plastic uveitis may result from 
the injury. 

Purulent uveitis of a not very pronounced type (purulent in- 
filtration of the vitreous humor, iritis, hypopyon) is very occa- 
sionally followed by sympathetic ophthalmitis, but, and it is a re- 
markable clinical fact, the marked purulent uveitis, which is 
called panophthalmitis (p. 264), may be said never to give rise 
to it. It is not a pyogenic micro-organism which causes sympa- 
thetic ophthalmitis, otherwise the latter would be a purulent 
process ; but it is rather some specific and non-pyogenic micro- 
organism ; and it can hardly be doubted that in those rare in- 
stances in which sympathetic ophthalmitis has followed on slight 
purulent uveitis, this specific organism has been present in the 
injured eye along with the staphylococcus. 

When the infection of the injured eye is purulent, the inflam- 
matory reaction comes on within the first thirty-six hours after 
the injury. The fibrinous or plastic inflammatory reaction, which 
is so dangerous in relation to sympathetic ophthalmitis, declares 
itself in the injured eye less quickly and more insidiously. The 
injection and irritation, the immediate result of the injury, disap- 
pear in a few days, only soon to return ; then the pupil begins to 
dilate less well to atropin, the tissue of the iris becomes less dis- 
tinctly seen, some posterior synechise form, and some opacities 
appear in the vitreous humor. At first there is little or no pain 
spontaneously or on pressure. Then fresh synechige form, the 
iris stroma becomes more indistinct and discolored, often of a 
dull greenish or yellowish gray, and the pupil becomes closed. 
The anterior chamber becomes shallower than normal, and the 
intra-ocular pressure is diminished. Sight is much affected by 
the exudation in the pupil and by the opacities in the vitreous, 
and, in case of detachment of the retina from shrinking of the 
inflammatory products in the vitreous humor, it may be reduced 
in a marked degree. There is often pain on pressure of the eye- 
ball, and the latter soon begins to be diminished in size and be- 
comes soft to the touch, while the pressure of the tendons of the 
orbital muscles on this soft eyeball gives rise to deep furrows on 
its surface. In short, the eye has now become phthisical, and 
sight is quite lost. This entire process may be completed in 
three or four weeks, or it may occupy a considerably longer time. 



THE UVEAL TRACT. 269 

The danger of sympathetic ophthalmitis supervening on a per- 
forating injury of the first eye commences with the onset of 
plastic uveitis in the first eye — although the inflammatory process 
in the second eye does not develop until after a certain interval 
(7nde infra) — and is present not only all through the acute 
process in the injured eye, but also after this has subsided, and 
when the eye has become shrunken, and even for many years 
more. 

Shrunken eyeballs, as just stated, are liable to cause sympa- 
thetic ophthalmitis. Pain on pressure of the ciliary region in 
them, showing, as it does, the presence of inflammation of the 
ciliary body, is an important danger-signal ; but the absence of 
pain on pressure is not conclusive of the absence of cyclitis, for 
the latter may exist to only a slight and yet dangerous degree, 
or the ciliary body may be detached and out of reach of pressure. 

The presence of a foreign body in the interior of the injured 
eye does not necessarily lead to sympathetic ophthalmitis by the 
inflammatory reaction which it may cause; for an aseptic for- 
eign body in the eye will cause an active inflammatory reaction ; 
yet this latter, not being of bacterial origin, will not in its turn 
give rise to sympathetic ophthalmitis. There are, however, few 
foreign bodies, except atoms of hot metal, which can be guar- 
anteed as aseptic. 

Similarly as in accidental perforating injuries, so also the 
wounds made in the sclerotic or cornea in operations, especially 
cataract extractions, may be followed by plastic uveitis, which 
will produce sympathetic ophthalmitis. In consequence of the 
thorough antiseptic measures now in use, inflammatory processes 
after cataract extractions are very much less common than they 
used to be. 

Perforations caused by ulcers of the cornea sometimes give 
rise to plastic uveitis, which may be followed by sympathetic 
ophthalmitis ; but this is an exceedingly rare event, although 
some iritis is present with almost every severe corneal ulcer, and 
especially with those which tend to perforate. It is not easy to 
assign a reason for the rare occurrence of plastic uveitis in these 
cases, unless it be the hypothetical one that there is some obstacle 
in the way of the passage of the bacteria into the deeper parts of 
the eye. 

In how far plastic uveitis of the first eye, which is not due to 
perforating injuries, is capable of being the cause of sympathetic 



270 DISEASES OF THE EYE. 

ophthalmitis is an important question. It was stated in the be- 
ginning that such a mode of origin is exceedingly unlikely. 

Intra-ocular tumors, which have not yet perforated the sclerotic, 
especially sarcoma of the chorioid, are said occasionally to set 
up a uveitis, which leads to sympathetic ophthalmitis. Schirmer ^ 
is disposed to regard the uveitis in these cases as being caused by 
an endogenous bacterial infection, and would refer the uveitis in 
the second eye to the same source, and not, therefore, to be looked 
upon as a sympathetic affection. But the matter may still be 
regarded as sub jndke. 

Ruptures of the eyeball from blows, which usually occur in 
the ciliary region, without rupture of the conjunctiva, come 
under our notice occasionally (p. 247). They almost invariably 
run a course free from inflammation, or even irritation of the 
injured eye, owing to the unbroken conjunctiva which covers the 
rupture and prevents the access of infecting bacteria, and, con- 
sequently, they do not cause sympathetic ophthalmitis. It is 
probable that in the few cases of this injury in which uveitis in 
the injured eye and sympathetic ophthalmitis in the second eye 
appeared, there existed some small opening in the apparently 
sound conjunctiva. 

Cases of gonorrheal ophthalmia have been published in which 
sympathetic ophthalmitis came on. But these were all cases in 
which ulceration took place, followed by perforation of the cor- 
nea ; and, hence, in which infection by bacteria other than the 
gonococcus was quite possible. 

Whether idiopathic or spontaneous inflammation of the uvea, 
such as those caused by gout, diabetes, syphilis, tubercle, and 
rheumatism, when they occur in one eye, are capable of giving 
rise to sympathetic ophthalmitis in the second eye, is a question 
which cannot at present be quite definitely answered. But it 
may be taken as almost certain, that the toxic substances or 
micro-organisms which circulate in the blood or lymphatics, and 
which cause the uveitis in the first eye, in a similar manner give 
rise to the uveitis in the second eye when it occurs ; and, conse- 
quently, that the uveitis in the latter is not to be regarded as sym- 
pathetic ophthalmitis. 

2. The Condition of the Sympathizing Eye. — The diseased 
process in the second or sympathizing eye, as has already been 
stated, is, with certain rare exceptions, an inflammation of the 
uvea, of a plastic or sero-fibrinous type, but never purulent, and 



THE U\'EAL TRACT. 271 

the inflammation almost alv/ays begins in the uvea, or, at any 
rate, is first discovered there as iritis. Occasionally optic neu- 
ritis is the first sign of sympathetic ophthalmitis, uveitis coming 
on subsequently, and, in the rare exceptions referred to above, 
optic neuritis has been seen as the one and only sympathetic in- 
flammation, the uvea remaining unaffected. It is, however, held 
by some, that optic neuritis is the first sign in the sympathizing 
eye in nearly all cases, if only they could be examined before 
opacities in the vitreous humor, and exudation in the pupil, inter- 
fere with an ophthalmoscopic diagnosis. 

The appearance of the optic neuritis, or papillitis, as seen in 
these cases, consists in hyperemia of the disc, without much 
swelling of it, but with slight wooliness of its margin, the opacity 
spreading a short distance into the surrounding retina. The 
veins are distended, and the arteries are normal. The sight is 
considerably affected, and there is often rather severe headache. 

The remedy for sympathetic papillitis is removal of the ex- 
citing eye, and a few days after the operation the beneficial effect 
on the optic nerve inflammation begins to show itself. This 
prompt response is evidence that the papillitis is not due to an 
invasion of bacteria, but that here it is rather their toxins which 
reach the sympathizing eye, and cause the papillitis. 

There are no reliable premonitory symptoms of the attack of 
uveitis in the sympathizing eye. As already stated, in many 
cases sympathetic irritation does precede the first signs of sym- 
pathetic uveitis, but it does not always do so ; and when svmpa- 
thetic irritation does appear, it need not always indicate the ap- 
proach of sympathetic uveitis. 

The early signs of the actual presence of uveitis in the svmpa- 
thizing eye are : some fine punctate deposits on the posterior sur- 
face of the cornea, and these are often the first symptom ; slight 
pericorneal injection; sHght opacity of the aqueous humor; some 
discoloration and indistinctness of the ins ; contraction of the 
pupil, but as yet no synechiae ; some fine opacities in the vitreous 
humor : and slight loss of sight owing to these changes. 

Posterior synechiae soon begin to form, and the adhesions 
occur in the most serious cases, not merely between the margin 
of the pupil and the anterior capsule of the lens, but, after a little 
while, between the whole of the posterior surface of the iris and 
the capsule. The exudation which causes this extensive adhe- 
sion soon pushes the iris forward, and renders the anterior cham- 



272 DISEASES OF THE EYE. 

ber shallow ; but after a time, when the fibrinous exudation be- 
gins to shrink, the anterior chamber becomes deep at its periph- 
ery, owing to retraction of the iris. The iris gradually be- 
comes more altered, its tissue more dull, discolored, and indis- 
tinct, while large vessels form in it. Occasionally, in the an- 
terior chamber a small hypopyon is seen, formed by the fibrin 
which floats in the aqueous humor, some of which has gravitated. 

The intra-ocular tension may become high, often very high, 
owing to blocking of the angle of the anterior chamber with in- 
flammatory products, and this glaucomatous tension is apt to be 
attended by great pain. In consequence of the presence of such 
extensive adhesions, eserin and pilocarpin have no influence on 
this high tension, and the temptation to perform an iridectomy 
is very great. Yet there is no more disastrous mistake in oph- 
thalmic practice than any operative interference at this period. 
Far from doing good, an iridectomy is almost certain to do harm. 
It is impossible, owing to the disorganized state of the iris and its 
close adherence to the anterior capsule, to obtain anything like 
a satisfactory coloboma ; and even if the tension be reduced after 
the operation for a day or two, it very soon becomes as high as 
ever, in consequence of the rapid filling up of the coloboma by 
fresh inflammatory products, while the traumatism of the opera- 
tion only seems to lend additional violence to the inflammation. 

The cornea gradually becomes more or less opaque, from de- 
rangement of its posterior epithelium by the punctate deposits 
of fibrin upon it, and the crystalline lens becomes cataractous. 
After a time the high tension disappears, and gradually low ten- 
sion comes on. Vision, already very bad, sinks further. The 
eyeball becomes less in size and very soft to the touch, and 
phthisis bulbi, with complete blindness, is presented. This en- 
tire process may occupy many months, and is often interrupted 
by short periods of slight improvement in the symptoms. 

It is rarely that cases occur in which the sympathetic uveitis 
comes on with violent pain, chemosis, and swelling of the eye- 
lids, and ends rapidly in phthisis bulbi. 

On the other hand, a less severe class of cases is met with, in 
which the whole posterior surface of the iris does not become ad- 
herent to the capsule of the lens, the pupillary margin alone be- 
coming adherent, and these cases may run a comparatively fav- 
orable course. Should the pupillary margin become adherent all 
round in these less severe cases, then increase of tension ensues 



THE UVEAL TRACT. 273 

from retention of aqueous humor in the posterior portion of the 
anterior chamber, with consequent bulging forward of the iris, 
and blocking of the angle of the chamber. 

A yet milder, and not uncommon, form of sympathetic uveitis 
is that in which the signs are : punctate deposits on the posterior 
surface of the cornea, and increased depth of the anterior cham- 
ber, without any iritis. The punctate deposits are at first often 
so fine as to be undiscoverable unless by aid of a high convex 
lens behind the sight-hole of the ophthalmoscope, or with a cor- 
neal microscope. This form of sympathetic ophthalmitis is 
termed serous sympathetic uveitis, and its prognosis is favorable. 
Its one danger consists in the increased intra-ocular tension which 
is liable to come on, but which should not tempt the surgeon to 
employ an iridectomy. 

More common than this typical serous uveitis are cases in 
which some fibrin is thrown out, with resulting posterior 
synechise at the pupillary margin. This form of sympathetic 
ophthalmitis is not attended by much irritation of the eye, nor 
need vision be much affected. The corneal deposits very gradu- 
ally increase in number, and consequently vision becomes affected 
to some extent, and then, if the tension does not increase, the 
signs and symptoms after a time very slowly abate, and a normal 
state is re-established. But relapses are liable to occur even 
after some months, and they may assume the very dangerous 
fibrinous type. So that, even in these mildest cases, the utmost 
care in treatment and prognosis is needed. 

Removal of the exciting eye does not cure the uveitis in the 
sympathizing eye (vide infra). 

3. The Interval zvJiieh elapses betzueen the Injury ta the Ex- 
citing Eye and the Onset of Uveitis in the Sympathizing Eye. — 
So far as our present knowledge based on reliable cases goes, 
the shortest interval is fourteen days, and very few cases with 
this shortest interval have been reported. The period between 
the sixth and twelfth week after the injury seems to be the most 
dangerous. In 170 of the 200 cases collected by the Committee 
on Sympathetic Ophthalmitis of the Ophthalmological Society ^^ 
the second eye was attacked within the first year after the injury 
to the exciting eye. In only 12 of the 200 cases was the inter- 
val more than one year, and the longest interval was twenty 
years. 

4. The State of the General System. — As the subjects of trau- 

23 



274 DISEASES OF THE EYE. 

matic plastic uveitis in one eye are not immune against plastic 
uveitis in the other eye due to syphilis, rheumatism, tubercle, 
diabetes, etc., it is necessary in each case to consider whether the 
attack in the second eye may not be a symptom of some systemic 
condition rather than a sympathetic uveitis. 

From the foregoing it appears, then, that the diagnosis of 
sympathetic ophthalmitis depends on circumstantial evidence, 
namely : ( i ) As regards the exciting eye : an ectogenic infection. 
(2) As regards the sympathizing eye: an inflammatory process 
of a plastic type which attacks all three portions of the uveal 
tract, is very chronic in its course, often improves for a while, 
but relapses again. Excision of the first eye does not cure sym- 
pathetic uveitis in the second eye ; yet, if the sympathetic affec- 
tion be an optic neuritis, it is rapidly cured by removal of the first 
eye. (3) As regards the interval between the perforating injury 
in the first eye, and the appearance of sympathetic ophthalmitis : 
an interval of at least fourteen days is required. The period 
between the sixth and twelfth weeks is the most dangerous, and 
very few cases occur after the first year. (4) As regards the 
general system : when careful examination of it does not reveal 
any condition which might be the cause of uveitis in the second 
eye, the probability of this uveitis being sympathetic is in- 
creased. 

Prognosis. — The prognosis of sympathetic uveitis is, in gen- 
eral, bad ; yet it need not be quite hopeless, for even in some 
severe cases, and of course more frequently in the less severe cases, 
the sym.pathizing eye does recover after prolonged treatment, 
with a useful amount of vision. But in the rather rare cases 
which undergo cure the eyes are liable to occasional recurrences 
of the uveitis, and at least a year should elapse since the last re- 
currence before a definite end to the diseased process can be said 
to have been reached. 

The prognosis of sympathetic papillitis is quite favorable when 
once the exciting eye has been removed. 

Treatment. — Prophylactic measures are of the first impor- 
tance. Where the traumatism is so extensive as to make all 
prospect of saving sight, or even the shape of the eyeball, hope- 
less, immediate excision of the globe is obviously indicated. In 
case some prospect of saving sight exists, our attention is claimed 
in the first instance by the wound in the injured eye, which, in 
those cases that come for surgical aid sufficiently early, is to be 



THE UVEAL TRACT. 275 

protected from secondary infection by careful antiseptic cleans- 
ing, abscission of any prolapsed portions of the uvea, suturing of 
the wound in suitable cases, and an antiseptic dressing and 
bandage. 

Should the wound be already infected, then excision of the 
injured eyeball, or such other operation (evisceration or neu- 
rectomy) as in the judgment of the surgeon will secure the 
second eye from the invasion of bacteria coming from the in- 
jured eye, is called for. No temporizing is admissible ; even 
some useful vision being, for the time, retained by the injured 
eye is not a contra-indication to the operation. 

Where sight in the injured eye is lost, it will not be difficult 
for the surgeon to recommend excision of the eyeball, and even 
to urge it on the patient ; but when some useful sight is still re- 
tained, it is not so easy to press this advice, although that should 
be done. We know, indeed, that in some cases of traumatic 
uveitis sympathetic uveitis does not supervene ; and, provided 
the first eye has not been too much disorganized by the injury, 
sight even in it may be ultimately obtained. But, unfortunately, 
we are unable to foretell whether any given case will run so fav- 
orable a course ; and to temporize, in the hope that it will do so, 
involves serious danger to the second eye, and, it may be, ultimate 
loss of all sight in each eye. 

In short, it cannot be doubted that there are cases, but prob- 
ably not many of them, in which, in the present state of our 
knowledge, we recommend removal of the injured eye, and 
where, had we decided to run a fearful risk by allowing it to re- 
main, not only would sight have been restored to it, but no sym- 
pathetic ophthalmitis would have come on. 

It must be further stated that we cannot feel sure that our 
removal of the first eye has averted sympathetic ophthalmitis 
from the second eye, until four weeks after the operation has 
elapsed. Nearly every ophthalmic surgeon has seen cases in 
which sympathetic ophthalmitis has appeared subsequently to 
excision of the first eye, and in which, at the time of the opera- 
tion, the second eye was perfectly sound. There are well- 
authenticated cases where sympathetic ophthalmitis appeared as 
long as four weeks after the enucleation of the injured eye. The 
assumption is that, in these cases, the infective micro-organisms 
had already started on their journey to the second eye, and had 
passed that point in the optic nerve of the injured eye where the 



2^6 DISEASES OF THE EYE. 

nerve was divided in the operation. Hence, in excising the eye- 
ball, it is very desirable to take away as much as possible of the 
optic nerve, by. severing it far back in the orbit. These cases 
are deplorable for the patient, and very trying for the surgeon, 
especially if the outbreak of sympathetic ophthalmitis should 
occur very soon after — perhaps the day after the operation. Yet 
where sympathetic ophthalmitis comes on after excision of the 
first eye, the operation need not be regarded as having been 
quite useless ; for experience shows that the attack of uveitis in 
the second eye is then usually of a comparatively mild type, and 
fairly amenable to treatment. 

In those cases in which the exciting eye has not yet been re- 
moved, and in which sympathetic ophthalmitis in the second eye 
has comm.enced, what are our duties? In the first instance, and 
at the earliest possible moment, removal of the exciting eye, 
always provided that it be quite and hopelessly blind. The im- 
mediate result on the second eye of removal of the first eye under 
these circumstances is not marked, for the inflammatory process 
in the former seems to proceed as actively as before. But statis- 
tics show that more sympathizing eyes are saved, or partially 
saved, when the injured eye has been removed soon after the 
outbreak of sympathetic ophthalmitis than when the injured eye 
is removed a considerable time after the outbreak, or not at all. 
Presumably when the source of supply of bacteria is withdrawn, 
the virulence of the sympathetic disease gradually subsides. 

But no exciting eye, which possesses even a slight degree of 
sight, should be removed when once sympathetic ophthalmitis 
has appeared, for it might happen that the sympathizing eye 
would become entirely lost, while the exciting eye might ulti- 
mately retain some degree of useful sight. Great caution is 
therefore required in deciding whether the exciting eye is capa- 
ble of recovering to a certain extent, and this frequently is a 
matter of considerable difficulty. Even a partially phthisical 
eyeball may sometimes ultimately come round sufficiently to gain 
useful vision. Schirmer ^ lays down the following rule : When 
sympathetic ophthalmitis has broken out, the exciting eye should 
not be removed unless it be absolutely blind ; or unless, if it still 
possess perception of sight, it has been for several weeks very 
soft and reduced in size ; or that, by reason of extensive corneal 
opacity, all hope of restoration to it of form-vision must be 
abandoned. 



THE UVEAL TRACT. 277 

If sympathetic ophthalmitis has broken out. either before or 
after removal of the exciting eye, the treatment and care of the 
sympathizing eye to promote its recovery must be considered. 
This consists in the use of atropin, warm fomentations, and sub- 
conjunctival injections, which latter are held by some to be very 
beneficial for the high tension. With these local means is com- 
bined a general and prolonged course of mercurialization — mer- 
curial inunctions or calomel internally, or both, care being taken 
to avoid any severe stomatitis. Diaphoresis, produced two or 
three times a week by means of pilocarpin (one-eighth to one- 
third of a grain according to the individual) hypodermically, 
and hot jars placed in the bed, is a useful adjunct. Salicylate of 
soda is now used in large doses (as much as one hundred and 
fifty grains in the day) by some surgeons. The patient is to be 
confined in one warm, but well-ventilated room, which should 
be kept almost dark. As this treatment must often be carried 
on for many weeks or even months, it is a trying one for the 
patient ; but it should be remembered that the issue at stake is a 
fateful one. 

No operation on the iris is to be performed so long as there 
is the slightest inflammation, or tendency to inflammation, and 
this rule holds good even if the tension of the eye becomes glau- 
comatous. Operative interference on the iris here has only the 
effect of lighting up fresh inflammation ; and even if the tension 
be reduced by an iridectomy, which owing to the diseased and 
degenerated state of the iris cannot be satisfactorily carried out, 
it will soon again become high. In six months or a year after 
every slight sign of inflam.mation (e. g., injection of the ciliary 
vessels on insertion of a spring speculum) has passed away — 
and a longer interval can only be of advantage — it may be al- 
lowable to perform an operation on the iris with the object of 
making an artificial pupil, always provided that there is good 
prospect of materially improving vision by this means. It must 
be remembered that, while every operation has its risks, the risks 
are unusually great in such disorganized eyes ; while any loss of 
sight is felt all the more in a case in which the eye operated on 
is probably the only one possessing even a little vision. On the 
other hand, when success crowns an operation in these sad and 
perplexing cases, the gain is great. 

If it be decided not to remove the exciting eye, after sympa- 
thetic ophthalmitis has broken out, then its treatment is conducted 



2/8 DISEASES OF THE EYE. 

on lines quite similar to those above recommended for the sym- 
pathizing eye, and the advice concerning operating on it is the 
same. 

Prophylactic^ Therapeutic, and Optical Operations 
USED IN Sympathetic Ophthalmitis. 

Prophylactic Operations. — These are: Enucleation, Eviscera- 
tion, Mules' Operation, Optico-Ciliary Neurectomy, and Optico- 
ciliary Neurotomy. 

Enucleation {or Excision). — For the performance of this 
operation there are two methods. 

1. O'Farrall's Method. — The speculum having been inserted, 
an incision is made in the conjunctiva all round the cornea, and 
about 6 mm. removed from the latter. The bulbar conjunctiva 
is separated from the globe freely in all directions with a scis- 
sors. With a strabismus hook each orbital muscle is caught up, 
and its tendon divided close to the sclerotic. The optic nerve is 
then divided with a strong scissors passed into the orbit from 
the median side. It is important to divide the optic nerve as 
far back in the orbit as possible, in order to include infective bac- 
teria which may have traveled thus far on their road to the 
second eye. Finally the edges of the conjunctiva are drawn 
together with a few points of suture. 

2. The Vienna Method. — The only instruments used in this 
operation, in addition to the speculum, are a strong straight 
scissors and a strong toothed forceps. The tendon of the in- 
ternal rectus at its insertion, with the overlying conjunctiva, is 
seized in one grasp with the forceps, and so held until the con- 
clusion of the operation. Immediately behind the forceps the 
tendon is divided with the scissors ; and now the forceps is 
holding merely the stump of the tendon adherent to the globe 
with the overlying conjunctiva. Through the opening neces- 
sarily made at the same time in the conjunctiva one blade of the 
scissors is passed, and pushed on under the tendon of the in- 
ferior rectus muscle, which is then divided along with the overly- 
ing conjunctiva. In the same way the superior rectus is divided. 
The globe is now drawn well forwards and rotated outwards, 
the scissors passed into the orbit, the optic nerve felt for and 
divided. With one or two strokes of the scissors the external 
rectus and the two obliques are divided close to the globe, and 
the operation is completed. This method is very rapid. It is 



THE UVEAL TRACT. 279 

not suited to any globe of which the walls are weak (fresh per- 
forating injury, extreme staphyloma, etc.), for a good deal of 
pressure is exercised on the eyeball during its performance. 

Careful aseptic and antiseptic precautions are to be employed 
in connection with enucleation of the globe. Of these, next 
to thorough sterilization of the instruments, I regard irriga- 
tion of the cavity of the orbit as soon as the eyeball is removed, 
with a full stream of sublimate solution, i in 5000, or of sterilized 
normal salt solution as the most important. The interior of the 
orbit is then well covered with xeroform, or other fine anti- 
septic powder, and an antiseptic dressing is applied with a band- 
age. The orbit should be similarly dressed every twenty-four 
hours. 

I have never seen the slightest trouble after enucleation of the 
eyeball ; but some cases of meningitis following upon the opera- 
tion, and which have proved fatal, are reported. There can be 
no reasonable doubt but that in these instances septic matter 
made its way along the lymphatics of the optic nerve to the 
meninges, and that this septic matter was introduced upon the 
instruments, or escaped, in purulent cases, from the interior of 
the eyeball. Hence the very great importance of the careful 
aseptic precautions above indicated. 

An artificial eye can usually be inserted after a fortnight, but 
should not be constantly worn for a month at least, as, until that 
period elapses, it is liable to cause irritation and conjunctivitis. 

Of prophylactic operations for sympathetic ophthalmitis, enu- 
cleation is the only one which is regarded by all as thoroughly 
reliable, when performed in good time. 

Evisceration. — For mode of performing this operation, vide 
p. 171. Although, so far as pubUshed cases teach us, eviscera- 
tion, as a preventive measure for sympathetic ophthalmitis, is as 
effectual as enucleation, yet there is the theoretical objection 
to it that no portion of the optic nerve is removed ; and that, if 
uveitis has commenced in the injured eye, the bacterial infection 
may have reached the head of the optic nerve prior to the opera- 
tion. Consequently, while the source of the infection — the uveal 
tract of the injured eye — has been removed, w^hat is contained 
of the infection in the nerve may continue on its way to the 
second eye, and set up sympathetic ophthalmitis. There can be 
no such objection to the employment of evisceration where it is 
performed quite soon after the injury, or at any rate before 



28o DISEASES OF THE EYE. 

uveitis has commenced. The advantage of evisceration over enu- 
cleation Hes in the better stump provided by it for a prothesis, 
and the consequent better cosmetic effect. 

Mules' Operation. — For the description of this operation, see 
p. 172. The objections to and advantages of this operation are 
the same as in evisceration,- but it gives a better stump than 
the latter. 

Optic-Ciliary Neurectomy. — An opening is made into the con- 
junctiva about 3 mm. behind the insertion of the internal rectus 
muscle ; this muscle is laid bare, and two curved blunt strabismus 
hooks are inserted beneath it. The hooks are draw^n in opposite 
directions, so that one is caught in the angle of insertion of 
the tendon with a tendency to roll the eye outwards, while the 
other will draw the muscle forwards out of the orbit. Near 
the latter hook a catgut thread is passed through muscle and 
conjunctiva, first from within outwards, and then the opposite 
way. The muscle is now divided at a distance of at least 5 mm. 
from its insertion into the sclerotic, and the ends of the catgut 
thread are tied in a knot. A second thread is passed through the 
terminal stump of the muscle, and similarly tied in a knot. The 
wound is now extended both towards the superior and inferior 
recti muscles, and a small pointed double hook is inserted into 
the sclerotic far back, in order to draw the globe forwards and 
outwards. A scissors curved on the flat is inserted alongside the 
globe, and the optic nerve is cut through as near the optic fora- 
men as possible. The posterior aspect of the globe can now be 
exposed to view by means of the double hook. The stump of the 
optic nerve remaining on the eyeball is then cut off near its in- 
sertion into the sclerotic, the insertion of the oblique muscles 
divided, and the whole of the posterior circumference of the 
sclerotic laid bare by dissection. The eyeball is replaced, the 
wound closed by means of the catgut threads previously intro- 
duced, and, as a precaution against sanguineous exophthalmos, 
the eyelids are united by three sutures. 

The advantage of this operation is that the_ eyeball is re- 
tained. 

It is now rarely performed, for it is not regarded as a very re- 
liable protection against sympathetic ophthalmitis, even when 
done sufficiently early ; and there is, moreover, a suspicion that, 
in some cases, the operation itself, or rather infection taking place 
during it, has excited sympathetic ophthalmitis. 



THE UVEAL TRACT. 281 

Optic-Ciliary Neurotomy. — The proceeding here is the same 
as for resection, except that only the first division of the optic 
nerve is made. For the prevention of sympathetic ophthalmitis 
this operation is open to the same objections as resection of the 
nerve, but in a greater degree. For the relief of sympathetic 
irritation, either operation may be employed, with at least tem- 
porary benefit, in suitable cases. 

Therapeutic Operations. — The field for these operations, if it 
exist at all, is exceedingly limited. Practically the only indica- 
tion for operative interference, in the active period of sympa- 
thetic ophthalmitis, is long-continued high tension; and in the 
foregoing pages the warning has been repeatedly uttered that 
any operative meddling with the iris in this period is more apt 
to aggravate the process than to alleviate it, and that even if 
tension be relieved by an iridectomy, it soon becomes high again, 
owing to fresh plastic exudation. 

Should it seem imperatively necessary to endeavor to reduce 
a long-continued high tension, sclerotomy is to be preferred to 
iridectomy. It may have a beneficial effect, and is not likely to 
do harm. It can be repeated more than once, should it be deemed 
necessary. 

Paracentesis of the cornea is a measure which can be used as a 
temporary means of relief for high tension, and it, too, may be 
repeated. 

Optical Operations. — The object of these operations is to 
provide an artificial pupil in the sympathizing eye, in order to 
improve, or to restore, vision which is interfered with by closure 
of the pupil. Similar operations may be indicated occasionally 
in the exciting eye, in cases where it has not been excised. 

The cardinal point to be borne in mind is that these opera- 
tions may never be performed until six months at least have 
elapsed — and a longer period is preferable, since all and every 
tendency to inflammation, or irritation, has subsided. Inatten- 
tion to this rule will result in a relighting of the inflammation, 
reclosure of the pupil which may have been made, and a long 
period of waiting before any further operation can be undertaken. 

Moreover, as even under the most favorable conditions, and 
with the most skillful operation, inflammation may return, or 
intra-ocular hemorrhage may occur, or the eye may become 
phthisical, no operation should be done unless the advantage to 
be gained from it, if successful^ promises to be considerable. 
24 



282 DISEASES OF THE EYE. 

The two chief operations, one or other of which may be ap- 
phcable, are: Iridectomy, and extraction of the clear or cata- 
ractous lens; for the lens is often cataractous from interference 
with its nutrition by the iridocyclitis. 

Iridectomy. — It is only exceptionally that iridectomy can be 
of use in those eyes which have been the subjects of the severer 
plastic uveitis, resulting in adhesion of the whole posterior sur- 
face of the iris to the anterior capsule. In these cases the tissue 
of the iris has undergone such extreme degeneration that it is 
impossible to obtain more than mere shreds of the membrane 
with the forceps, so that a satisfactory coloboma can rarely be 
made. Or, if a fairly good coloboma be procured, it will prob- 
ably be found that the pigmentary layer of the iris is left behind ; 
and that this, with organized inflammatory products, lies on the 
anterior capsule, and obviates any gain that might have been de- 
rived from the coloboma. 

Iridectomy is indicated rather in those cases where a less 
severe form of iritis has existed, resulting in a complete ring 
synechia of the pupillary margin only. Here a wide coloboma 
may often be made satisfactorily. The iris should be seized with 
the forceps at about the lesser circle. If seized at the pupillary 
margin, the intimate adhesion between the latter and the lens 
capsule may cause injury to the capsule, and consequent trau- 
matic cataract. 

Extraction of the Lens. — This is indicated, if, on the forma- 
tion of a coloboma, the lens be found to be cataractous ; in those 
cases of ring synechiae where iridectomy has been performed and 
the coloboma has closed again ; and in practically all cases ot 
total adhesion of the iris to the capsule, be the lens clear or 
opaque. In the former class of cases the ordinary combined 
method of cataract extraction answers the purpose, or a pre- 
liminary iridectomy may be made some weeks previously. 

Cases of total adhesion of the iris require a different pro- 
cedure. A very wide incision is made in the cornea. The knife, 
having been entered at the outer side, is passed through iris and 
lens ; the latter is then delivered as completely as possible, and 
out of the membrane composed of degenerated iris, retro-iridic 
connective tissue, and capsule, a V-shaped piece is cut with the 
forceps-scissors. 

Discission. — This operation was employed by the late Mr. 
George Critchett with much success in some cases where cataract 



THE UVEAL TRACT. 283 

was the main obstruction to sight. A discission needle is passed, 
by a boring motion, through the lenticular capsule; another 
needle is then passed in close to the first, and by separating one 
point from the other a rent is made in the center. This is 
followed generally by the escape into the anterior chamber of a 
small quantity of cheesy lens matter, which becomes gradually 
absorbed, and in the course of some weeks the capsule closes 
again. The operation has to be repeated several times before a 
clear pupil is obtained, care being taken that all irritation from 
the previous operation has subsided before another is under- 
taken. The danger in this method would be irritation and high 
tension from swelling of the lens in a disorganized eye, and I 
do not know that the method has been much used by other sur- 
geons. 

Pathogenesis. — The pathogenesis of sympathetic ophthalmitis 
is still surrounded by obscurity. An old view was that irritation 
cf the ciliary nerves in the exciting eye caused an irritation of the 
ciliary nerves in the opposite eye, which irritation, in its turn, 
gave rise to inflammation in this second eye. But modern pa- 
thology teaches that there is no such thing as reflex inflammation. 

There are, nowadays, two chief theories, each of which 
relies on bacterial infection of the sympathizing eye by specific 
organisms of the process coming from the exciting eye. But 
these theories differ from each other in respect of the path by 
which they would respectively make these organisms pass from 
the first to the second eye. Neither school, it must be stated, 
has been able, by present-day methods, to identify the bacteria 
which set up the inflammation. Yet this cannot be held to be a 
supreme objection to either theory, for there are many bacterial 
diseases — e. g., syphilis, rheumatism, smallpox — the micro-organ- 
isms of which our present methods have failed to demonstrate. 

According to the theory which numbers most adherents, the 
path which the infective organisms take in passing from the ex- 
citing to the sympathizing eye is along the lymphatics of the 
optic nerve, or its sheaths, of the first eye, then by the optic com- 
missure, and down the optic nerve of the sympathizing eye — 
in short, by direct continuity, as erysipelas extends over the skin. 
This view, which was first put forward by Leber,^ is maintained 
by many trustworthy authorities. Deutschmann,* indeed, 
semed to have definitely proved the case by experiments on ani- 
mals. He injected the staphylococcus pyogenes into one eye, 



284 DISEASES OF THE EYE. 

and thus produced a uveitis in the other eye. Not only this, but 
he discovered the coccus in the optic nerve sheath of the exciting 
eye, and also in that of the sympathizing eye. Many others have 
repeated his experiments, but no one has obtained the same re- 
sults. Moreover, the inflammatory process, which the staphylo- 
coccus pyogenes produces, is purulent, while sympathetic oph- 
thalmitis is a sero-plastic or fibrinous process. The theory has 
yet to be shown to be correct by experimental research, or, what 
would be preferable, by pathological demonstration in the hu- 
man subject. For the present it relies on cHnical evidence, and 
it is, moreover, in accord with .accepted pathological principles. 

The other view, propounded by Schmidt-Rimpler,^ explains 
the infection of the sympathizing eye as a manifestation of a 
bacterial infection of the general system from the exciting eye. 
The germs, it is suggested, enter the general circulation, and 
travel through all parts of the body, but find a suitable home only 
in the fellow-eye. 

Injuries. 

Injuries of the Iris. — Punctured Wounds of the cornea, or of 
the corneo-scleral margin, frequently implicate the iris, but rarely 
do so without also injuring the crystalline lens or ciliary body, 
on which then the chief interest centers, as being the organs from 
which serious reaction is most likely to emanate. A small, simple 
incised wound of the iris is not of great importance, for inflam- 
matory reaction is not common, and any extravasation of blood 
at the seat of the iris wound, or into the anterior chamber (hy- 
phemia) becomes absorbed, while, in most cases, the functions of 
the iris will probably not be affected nor sight endangered. 
Nevertheless, as iritis does sometimes occur, it is desirable to use 
such measures as are calculated to prevent it, such as atropin, 
a bandage, and rest of the eye and general system. Even exten- 
sive wounds of the iris are not often, as such, associated with 
serious danger to the eye, although the loss of continuity in the 
iris never closes up. Where, for instance, the iris is cut in its en- 
tire width from ciliary margin to pupillary margin, the perma- 
nent result is a wide coloboma, the margins of which may be 
adherent to the corneal wound. When the iris is prolapsed in 
the corneal wound, every effort should be made to reduce it com- 
pletely; and, if this cannot be affected, it is necessary to abscise 



THE UVEAL TRACT. 



28s 



the prolapsed portion. Incarceration of the iris in the corneal 
cicatrix may lead to secondary glaucoma, cystoid cicatrix, sec- 
ondary septic infection of the iris, etc. 

Foreign Bodies of small size, such as bits of steel or iron, may 
perforate the cornea and fasten in the iris, the puncture in the 
cornea closing rapidly, and possibly no aqueous humor being 
lost. It is necessary always to remove such a foreign body 
without delay, although for some time it may cause no reaction. 
An incision should be made with a Graefe's knife at the margin 
of the cornea corresponding to the position of the foreign body, 
and the portion of iris containing the foreign body is then 
removed with forceps and scissors. 

Blows on the Eye are apt to cause, in addition to hemorrhage 
into the anterior chamber from the iris or from the canal of 
Schlemm, one of several remarkable lesions of the iris, namely: 




Fig. 92. 



I. Iridodidysis "^^ — i. e., separation of the iris from its attach- 
ment to the ciliary body, which is usually accompanied by con- 
siderable hyphemia. As much as one-half of the circumference 
of the iris may be involved in the lesion, or the latter may be 
so small as to be diagnosed only by the presence of the result- 
ing small fresh hemorrhage near the ciliary margin of the 
iris; or, after this has become absorbed, by aid of light trans- 
mitted to the eye by the ophthalmoscope, and then not only the 
physiological pupil, but also the minute marginal traumatic pupil, 
will be illuminated. It is rarely that there is more than one 
dialysis. In certain degrees of the detachment, by reason of the 
sphincter of the iris having lost its fixed point, it becomes 
stretched in a straight line (Fig. 92) at the part corresponding 
to the dialysis, and assumes a D-shape, or if the detachment be 
more extensive, the pupil becomes kidney-shaped, or the de- 

* IpiQ ; 6Lakvaiq, a separating. 



286 DISEASES OF THE EYE. 

tached portion may entirely cover the pupil. The detached por- 
tion, too, may be turned on itself (anteflexion of the iris), the 
uveal surface being to the front. The functions of the eye after 
such an injury, even when extensive, may be but little disturbed, 
or there may be monocular diplopia. 

It is stated that iridodialysis does not become re-attached ; but 
I have observed one case in which a very minute one was healed, 
and there is one other such case recorded. The lengthened use 
of atropin is the most likely way in which to promote such a 
result, but it can only be hoped for if the iridodialysis be not 
extensive and the case be seen early. 

Iridodialysis does not increase in extent in the course of time, 
nor lead to further mischief in the eye. 

2. Retroflexion of the Iris. — The whole, or more commonly 
a portion, of the iris in its entire width becomes folded back on 
the ciliary processes, giving the appearance of a very dilated pupil 
or of a coloboma produced by a wide and peripheral iridectomy. 
In a true coloboma the ciliary processes would be easily seen, 
but not so in retroflection, for the processes, being covered by 
the retroflexed iris, present a smooth surface. A slight disloca- 
tion of the lens in the direction away from the iris lesion is often 
observed. Retroflexion of the iris cannot be cured, but useful 
vision is retained, if the injury be uncomplicated. 

3. Rupture of the Sphincter Iridis. — There are not many cases 
of this lesion recorded ; although, according to Hirschberg, in 
all cases of permanent traumatic mydriasis the margin of the 
pupil is torn. My observations do not agree with his, nor do I 
think that rupture of the sphincter would be sufficient to ac- 
count for the traumatic mydriasis which is usually associated with 
it. There may be but one rupture, or there may be a number of 
small ruptures distributed round the pupil. They show them- 
selves as small triangular gaps in the pupillary margin, their 
bases directed towards the latter. This condition is also in- 
curable, and some permanent disturbance of vision due to the 
mydriasis results. 

4. Dehiscence of the Iris between the pupillary and ciliary 
margins. This is a slit-like rupture of the iris which runs in a 
radial direction through the whole width of the iris with the ex- 
ception of the sphincter. The diagnosis sometimes cannot be 
made with certainty until, after a few days, the blood-clot cov- 
ering the dehiscence is absorbed. The opening may be caused 



THE UVEAL TRACT. 287 

to close by the use of a myotic, which, by contracting the sphinc- 
ter, brings the edges of the dehiscence together. 

5. Traumatic Aniridia. — The whole iris is torn from its ciliary 
insertion, and may be found lying in the anterior chamber or 
under the conjunctiva, having in the latter case passed through 
a rent at the corneo-scleral margin. Not only does the anterior 
chamber contain blood, but the vitreous humor is often in- 
filtrated with hemorrhage. When the extravasated blood has be- 
come sufficiently absorbed, the absence of the iris will be noted, 
and in many instances the ciliary processes will be visible. If 
these latter are visible the diagnosis " aniridia " can be definitely 
made, but cases do occur in which, notwithstanding the absence 
of the iris, the ciliary processes are not visible, owing prob- 
ably to changes in the processes which cause them to shrink. 
Such cases then are difficult to distinguish from retroflexion of 
the iris, but the importance of the diagnosis is not great. 

6. Traumatic Mydriasis, and Myosis. — Of these, mydriasis is 
the more common. The dilatation is of medium degree, and the 
pupil is usually of irregular shape — oval, pear-shaped, or more 
dilated at one part than elsewhere — and contracts but slightly, or 
not at all, to light. Paralysis of accommodation usually accom- 
panies traumatic paralysis of the sphincter iridis. The mydri- 
asis is probably the result of concussion of the delicate nerve-end- 
ings in the sphincter of the iris. (See above, under Rupture of 
the Sphincter Iridis.) 

With traumatic myosis there is apt to be spasm of accommo- 
dation, which may produce apparent myopia. The prognosis is 
fairly good. Traumatic mydriasis may recover after a long 
interval, but in most instances it remains as a permanent defect, 
with some defect of vision due to it, and to the paralysis of ac- 
commodation. 

Treatment. — For mydriasis, protection spectacles, galvanism, 
and eserin. For myosis, atropin. 

Injuries of the Ciliary Body. — Punctured Wounds, and For- 
eign Bodies, perforating the sclerotic at a distance of about 5 
mm. around the cornea, are almost certain to implicate the ciliary 
body. If there be no prolapse of the ciliary body, nor any for- 
eign body in the interior of the eye, the sclerotic wound may 
heal by aid of a bandage without further ill results. If a pro- 
lapse of the ciliary body or iris be present, it is to be abcised, 
with careful antiseptic measures ; and if the sclerotic wound be 



288 DISEASES OF THE EYE. 

large, it may be thought desirable to unite its margins with 
sutures. 

Wounds of the ciliary body are apt to cause cyclitis, especially 
if the former be incarcerated in the sclerotic wound in healing, 
for the incarcerated portion is liable to become infected. 

Injuries of the Chorioid. 

Small Foreign Bodies may pierce the sclerotic, or the cornea 
and lens, and lodge in the chorioid, and, if favorably situated, 
can be detected with the ophthalmoscope, but in any case by the 
Rontgen rays if of metal. They require operative removal by 
the magnet, if of steel or iron ; or if the foreign body cannot 
be extracted, the eyeball must be removed, to avert sympathetic 
ophthalmitis. 

Incised Wounds of the sclerotic very frequently involve the 
chorioid (see p. 248). 

Rupture of the Chorioid is often produced by blows on the 
eye, and is seen with the ophthalmoscope as a whitish-yellow 
(the color of the sclerotic) crescent some two or three papilla- 
diameters in length, and one papilla-diameter or so distant from 
the optic entrance, the concavity of the crescent being directed 
towards the papilla. Immediately after the accident extrava- 
sated blood sometimes prevents a view of the rupture. Some 
chorioiditis may result ; but, when this passes away, good vision 
is frequently restored and maintained, provided detachment of 
the retina does not ultimately supervene from cicatricial contrac- 
tion at the seat of the rupture. On the other hand, a scotoma 
in the field may be produced, and if the rupture be in the re- 
gion of the macula lutea, serious loss of sight may be caused. 

Treatment. — Careful protection of the eye, and iabstinence 
from use of it, with dry cupping at the temple for three weeks, 
or until it may be assumed that all inflammatory tendency has 
subsided. 

Blows upon the eye may cause Extravasation of Blood in the 
Chorioid. If small, these extravasations do not extend beyond 
the chorioid. But in the case of copious extravasation the hem- 
orrhage is poured out from the chorioidal vessels between that 
coat and the sclerotic, lifting and bulging forward the chorioid; 
or between the chorioid and retina, giving rise to a detachment of 
the latter; and if the retina gives way, the blood is poured out 



THE UVEAL TRACT. ^ 289 

into the vitreous humor. Should there be no vitreous humor 
opacity, the extravasations in the chorioid can be seen with 
the ophthahnoscope as somewhat indistinct (owing to result- 
ing opacity in the overlying retina) small red spots, or large 
round red spots, darker in the center than at the margin. That 
these hemorrhages are in the chorioid can be recognized from 
the fact that they lie behind the retinal vessels. The hemorrhages 
become slowly absorbed, and after a time, provided the retina has 
not burst, useful vision may be restored. 

Treatment. — Complete rest in bed. Atropin. Bandage. 

New Growths. 

New Growths of the Iris. — Cysts. — These vary from a very 
small size to that which would fill the anterior chamber. They 
may have either serous or solid contents. The serous kind was 
said to result always from a trauma causing an anterior synechia, 
or otherwise shutting off a fold of the iris, which became dis- 
tended into a cyst by accumulation of aqueous humor. A case, 
however, which was not preceded by a trauma has come under 
my notice. The cysts with solid contents (epidermoid elements) 
are believed to have their origin in an eyelash or morsel of epi- 
dermis, which may have made its way into the anterior chamber 
by occasion of a perforating corneal wound. All these cysts 
are sources of serious danger to the eye (irido-chorioditis, glau- 
coma, etc.), and, it has been stated, may even be the cause of 
sympathetic ophthalmitis, and hence their removal is called for. 
This can be effected without much difficulty if the tumor be small, 
but if it have attained a large size the attempt may be unsuc- 
cessful. A long incision should be made in the corneo-scjeral 
margin, and the cyst, along with the portion of iris to which 
it is attached, drawn out and cut off. 

Granuloma is the name given to a benign neoplasm of the iris, 
of which the structure resembles granulation tissue. Clinically 
it is a small pale tumor, or there may be several such tumors, 
which gradually grow to fill the anterior chamber, rupture the 
cornea, and finally induce phthisis bulbi. It is held by some that 
these growths depend on a syphilitic taint, and by others that 
they are tubercular. 

Tubercle {Tubercular Iritis). — This disease occurs generally 
in children or young adults, who may or may not present evidence 



290 DISEASES OF THE EYE. 

of general tuberculosis, such as enlarged or caseating glands, or 
diseases of joints, etc. It is met with in two forms — viz., dis- 
seminated or miliary tubercle, and conglomerate or solitary 
tubercle. 

Miliary Tuberculosis of the iris is a relatively mild form, 
which presents the clinical appearances of a chronic iritis, some- 
times with punctate corneal deposits; but it is chiefly character- 
ized by the formation of a number of grayish or cinnamon-col- 
ored, semi-translucent nodules on the surface of the iris and at 
the angle of the anterior chamber. Occasionally they are not very 
numerous. The disease may either run its course, and finally 
cause shrinking" of the eye from plastic iridocyclitis, or it may 
subside even without treatment. It is to this form of iritis that 
Leber ^ has given the name attenuated tuberculosis of the iris ; 
but it is not due to any attenuation of the virus, for inocula- 
tion in the anterior chamber of a rabbit's eye of an excised portion 
of such an iris produces severe local and general tuberculosis. 

Solitary tubercle may be accompanied by a few smaller 
growths, but it generally begins as a single yellowish-white 
tumor, often without iritis, which gradually increases in size 
until it may fill the anterior chamber. It finally involves the 
cornea, which it perforates, forming a fungating mass, and this, 
subsequently, breaks down, leaving only a small stump in the 
socket. Microscopically both varieties present the usual struc- 
ture of tubercle, but bacilli are very difficult to detect in either of 
them. 

Treatment in the miliary forms consists of the usual local and 
constitutional means. Internal administration of creasote has 
been recommended. If the disease continue to progress, enuclea- 
tion may be necessary. 

Should a solitary tubercle be seen in an early stage, it may 
be removed by an iridectomy ; but if the disease have advanced 
too far, or the iridectomy have failed, the eye must be extir- 
pated. Operative treatment will depend very much on the view 
which the surgeon takes of the origin of the disease. It has 
until recently been generally believed that, while tubercle of the 
chorioid was a disease secondary to tuberculosis elsewhere, 
tubercle of the iris was a primary affection, and as such necessi- 
tated immediate enucleation of the eye, in order to prevent it 
from becoming a source of general infection. The impression, 
however, seems to be growing that tubercle of the iris is also a 



THE UVEAL TRACT. 291 

secondary affection, and that, consequently, enucleation is not 
always indicated, with the object of averting tubercular disease 
of the general system. Of course in those cases, which are not 
uncommon, where both eyes are affected, the question of enuclea- 
tion cannot be entertained. 

Sarcoma. — Of the uveal tract, the iris is the portion most rarely 
affected with primary sarcoma. It arises usually from a con- 
genital pigmented nevus of the iris, and is commonly a melano- 
sarcoma; but leuko-sarcoma has also been recorded. As the 
tumor increases in size, it fills the anterior chamber, and grows 
backwards into the ciliary body and into the canal of Schlemm. 
It is not usual for the tumor to become extra-ocular by growing 
through at the corneo-scleral margin, and in this respect it is un- 
like tubercle of the iris. Irritation or inflammatory symptoms 
are not often present, and secondary glaucoma does not come on 
until a later stage, when the growth has filled the anterior cham- 
ber, or involved the ciliary body extensively. 

Treatment. — Enucleation of the eye should be advised as soon 
as the diagnosis of sarcom.a of the iris has been made. There 
is naturally a desire on the part of the surgeon, when the tumor 
is small, to save the eye, which probably has full vision, by ex- 
cising the portion of iris in which the growth is seated, and there 
are some cases on record in which this was done, and where no 
recurrence of the tumor took place. But in adopting this con- 
servative method, the surgeon accepts grave responsibility; for 
it is not possible to determine clinically whether the sarcomatous 
growth is truly, or only apparently, confined to the limited region 
of the iris, where it can be seen. Even in the early stages of 
many cases of sarcoma of the iris the neoplasm invades the liga- 
mentum pectinatum, the canal of Schlemm, or the ciliary body; 
so that, although the iris tumor be thoroughly removed, the 
growth reappears in the eye before long, while in the meantime 
risk of infection of the general system has been run. 

Ophthalmia Nodosa is a very rare affection, of which about a 
dozen cases have been recorded. It is caused by the irritating 
secretion contained in the hollow hairs of certain caterpillars. In 
nearly all cases there was a history of caterpillars having acci- 
dentally come into forcible contact with the eye. The disease, 
which is very chronic, is characterized by the presence of small 
hard nodules in the conjunctiva and iris, and may lead to severe 
iridocylitis. The diagnosis is confirmed by the preseyice of 



292 DISEASES OF THE EYE. 

brownish hairs; or by the examination of an excised nodule, 
which shows the hair in sections as a yellow oval body with a 
central cavity. 

New Growths of the Ciliary Body. — Sarcoma of the ciliary 
body is generally pigmented, and often passes unobserved, until 
it attains considerable size as a brown mass, which was at first 
concealed from view by the iris. Occasionally it is first noticed 
when it makes its appearance at the angle of the anterior cham- 
ber. It usually also grows backwards into the chorioid, and 
runs the same course as sarcoma of the chorioid. Removal of 
the eyeball should be urged, and may for a time be declined by 
the patient, as sight is but slightly affected in the early stages. 

Myosarcoma originaiing in the ciliary muscle has been ob- 
served a few times. 

Carcinoma. — Primary carcinoma of the ciliary body is an ex- 
tremely rare disease. Its occurrence in this situation is easily 
explained if the ciliary body, which secretes the intra-ocular fluid, 
has a glandular structure; and, from the researches of Collins,'^ 
there seems to be every reason to believe that it does contain 
tubular glands. 

Secondary carcinoma may occur in the ciliary body as in the 
chorioid (vide infra), but is very rare. 

New Growths of the Chorioid. — Sarcoma is by far the most 
common neoplasm of the chorioid, and the chorioid is the most 
common seat of ocular sarcoma. It is seen at all times of life, 
but most frequently between the ages of forty and sixty. Both 
melano-sarcoma and leuko-sarcoma occur, and may originate in 
any part of the chorioid. 

If seen in a very early stage, it is easily recognized from 
its projecting over the general surface of the fundus, the retina 
lying closely applied to it; but, unless it be in the region of the 
macula lutea, it may not cause any serious disturbance of vision, 
and hence may not at that period be brought under the notice of 
the surgeon. The diagnosis from detachment of the chorioid 
at this stage is made by the presence in the latter condition of the 
characteristic chorioidal vessels, and by the peculiar color of the 
chorioid. Detachment of the chorioid, too, is much rarer than 
sarcoma. 

The new growth soon gives rise to detachment of the retina by 
reason of serous exudation from the chorioid ; and this may be 
accompanied by opacity in the vitreous humor, which contributes 



THE UVEAL TRACT. 293 

to render the diagnosis with the ophthalmoscope difficult or im- 
possible. If the detachment be shallow and the retina trans- 
lucent, the tumor may still sometimes be seen through the sub- 
retinal fluid by aid of strong illumination; and even direct sun- 
light may be employed in some such cases. Owing to the great, 
and often sudden, defect of vision which comes on in this stage, 
we very commonly see these cases then for the first time. The 
history of the case may aid us ; while the absence of the more 
usual causes of detachment of the retina should make us sus- 
picious of an intra-ocular tumor, and the fundus should be care- 
fully examined, with dilated pupil, in all such cases. 

Soon the intra-ocular tension increases. This makes the diag- 
nosis again more easy in many cases, for the combination of 
detached retina and increased tension exists only with intra- 
ocular tumors. The increased tension may come on very slowly, 
and without ciliary neuralgia; or more rapidly, and with all 
the signs and symptom.s of acute glaucoma. Still, if the case 
come now under observation for the first time, the diagnosis 
may be by no means easy, should the refracting media be opaque 
(as always in acute glaucoma), and consequently the detach- 
ment of the retina concealed from view. Here, again, the his- 
tory of the case is all we have to depend on, especially the fact 
of the patient having noticed a defect at one side of his field 
of vision previous to the onset of glaucoma. 

In the next stage of the growth it perforates the cornea or 
sclerotic, and, increasing rapidly in size, although still covered 
with conjunctiva, it pushes the eyeball to one side, the upper lid 
being stretched tightly over the whole. On raising the lid the 
tumor is seen as a bluish-gray mass with irregular surface. 
The conjunctiva is now soon perforated, and the surface of the 
tumor becomes ulcerated, with a foul-smelling discharge and 
occasional hemorrhages. The tumor gradually invades the sur- 
rounding skin and the bones of the orbit, and by extending 
through the sphenoidal fissure and optic foramen reaches the 
base of the brain. 

Another, and less usual, course of chorioidal sarcom.a is that 
in which, without first perforating the cornea or sclerotic, the 
tumor sets up irido-cyclitis, leading to phthisis bulbi. 

It is usually upon the neighboring tissues of the eyeball becom- 
ing involved that secondary growths begin to form in other 
organs, the one most prone to be affected being the liver. The 



294 DISEASES OF THE EYE. 

lungs, stomach, peritoneum, spleen, and kidneys may all be at- 
tacked. 

Chorioidal sarcoma is almost always primary, but it has been 
seen a few times as a metastatic disease. 

The entire progress of such a growth varies considerably. It 
may occupy but a few months, or it may extend over many 
years. 

Cases in which sarcoma of the chorioid was present in shrunken 
eyeballs have given rise to the view that such eyeballs are prone 
to develop sarcoma. While it is quite possible that sarcoma may 
develop in a shrunken eyeball, it is tolerably certain that in the 
majority of the cases in which both diseases are present the 
sarcoma is the primary disease.^ 

Carcinoma. — This is extremely rare, and the cases of it on 
record were all of metastatic origin, the primary disease being in 
the breast. It is not possible to distinguish chorioidal sarcoma 
from chorioidal carcinoma by the ophthalmoscope. 

Tubercle is sometimes seen in cases of acute miliary tuber- 
culosis as round, slightly prominent, pale yellowish spots, of 
sizes varying from 0.5 to 2.5 mm. in diameter, situated always 
in the neighborhood of the optic papilla and macula lutea, and 
unaccompanied by pigmentary or other chorioidal changes. There 
may be but one of these tubercles, or there may be many of 
them. They occur as a rule in a late stage of the general dis- 
ease, but have occasionally been noted long before its appearance. 
In obscure cases of the general disease, the ophthalmoscope has 
sometimes rendered valuable diagnostic aid by discovering these 
minute tubercles in the chorioid. 

Very rarely a tubercular tumor grows in the chorioid in cases 
of general chronic tuberculosis, and attains a large size, the 
growth destroying the eye similarly as sarcoma or carcinoma. 
In young children it may be impossible to diagnose between a 
tubercular tumor of the chorioid and a glioma of the retina 
(chap. XV.). Yet, as in either case enucleation is indicated, 
the diagnosis is not of much practical importance. 

Other, but rare, forms of tumor of the chorioid are : 

Sarcoma Carcinomatosum and Osteo-Sarcoma. 

Treatment. — So long as, in cases of sarcoma and carcinoma, 
the tumor is wholly intra-ocular, enucleation of the eyeball should 
be performed, and may be done with fair hopes of saving the 
patient's life, if the disease be primary. When the orbital tissues 



THE UVEAL TRACT. 295 

have become involved, extirpation of all the contents of the 
orbit, and even, if necessary, removal of portions of its bony 
walls, ought to be undertaken, should the general health permit, 
in order to rid the patient of his loathsome disease; although 
the probable presence of secondary growths elsewhere renders 
but small the prospect of saving the patient's life. 

Cases of miliary chorioidal tubercle do not call for direct treat- 
ment. In cases of tubercular tumor the question of removal of 
the eyeball must depend upon the general state of the patient ; 
but if it seem probable that life will be prolonged until after 
the ocular growth would become extra-ocular, removal of the 
eye should be recommended. 

Other Diseases of the Chorioid. — Posterior Sclero-Chorioi- 
ditis, or Posterior Staphyloma. — This condition is described in 
connection with myopia (p. 46), which is its almost constant 
cause. 

Detachment of the Chorioid. — As the result of copious loss 
of vitreous, during operations, or from injury, detachment of 
the chorioid is not uncommon, but it does not require to be spe- 
cially diagnosed in these instances, and, therefore, it is not im- 
portant to consider it further here. 

But idiopathic detachment of the chorioid, although extremely 
rare, is of importance, as forming a well-defined diseased condi- 
tion in itself. 

The ophthalmoscopic appearances here are apt to be taken at 
first sight for a simple detachment of the retina, or for leuko- 
sarcoma ; but on closer inspection the chorioidal stroma is ob- 
served to lie immediately behind the detached retina, and its 
vessels, etc., are seen in the upright image by aid of the same 
lens as are the retinal vessels. The chorioid is not everywhere 
detached, but is separated from the sclerotic in several differ- 
ent places, and these detachments are seen in the form of ap- 
parently solid hemispherical protuberances rising abruptly from 
the fundus into the vitreous humor. In other places the chorioid 
is in contact with the sclerotic, although in some of these posi- 
tions there may be detachment of the retina alone. The vitreous 
humor is more or less opaque. Needless to say, vision is greatly 
lowered or quite destroyed. 

It is probable that a chronic chorioido-retinitis has been an 
antecedent condition in all of these cases. Indeed, there often 
are signs of old retinitis present, such as perivasculitis and con- 



296 DISEASES OF THE EYE. 

nective tissue striation ; and in one case a retinitis was actually 
observed long before the detachment of the chorioid came on. 
Adhesions between the chorioid and sclerotic are formed in 
consequence of this inflammation ; and then inflammatory exuda- 
tion takes place behind the chorioid, and separates it from the 
sclerotic, where it happens not to be adherent to the latter. 

The process ends either in phthisis bulbi, in consequence of 
vascular changes and disturbances of nutrition, or in cure of a 
certain degree, in so far as by absorption of some of the exuda- 
tion, and by alteration of the remainder of it into connective 
tissue, a return of the chorioid and retina to their normal position 
is rendered possible ; but even then restoration of sight, with 
tissues so disorganized, cannot be looked for. 

Treatment hitherto seems to have been of no avail. Probably 
active mercurialization might afford the best chance of doing 
good, should a case come under notice. 

Fuchs has pointed out that detachment of the chorioid occurs 
in a good many cases of cataract extraction some days after the 
operation, and also in some cases of iridectomy. It can often 
be found with the ophthalmoscope, and even sometimes with the 
oblique illumination, in those cases of cataract extraction in 
which the anterior chamber has not formed, or in which, hav- 
ing formed, it has become empty again. It is mainly after iri- 
dectomy for chronic simple glaucoma that chorioidal detach- 
ment has been noticed. The probable explanation is that a 
slight aperture of communication has been made between the 
anterior chamber and the subchorioidal space, through which 
the aqueous humor passes behind the chorioid. With the re- 
establishment of the anterior chamber, the chorioidal detachment 
goes back, and the prognosis is in all cases good as regards 
vision. 

Central Senile Areolar Atrophy of the Chorioid. — This is not 
a very rare disease, and presents the appearance of a white patch, 
often of considerable extent, at and around the macular region. 
In some cases a hemorrhage in the chorioid and posterior layers 
of the retina form the starting-point of the disease. The retinal 
functions always suffer much ; for an absolute central scotoma is 
produced, which renders reading and writing impossible, although 
locomotion is not much impeded, as the periphery of the field re- 
mains intact. The discovery of the presence of this disease, after 
a cataract has been successfully removed, is sometimes a source 



THE UVEAL TRACT. 297 

of intense disappointment both to patient and surgeon, which 
cannot be guarded against unless it has been noted while the 
cataract was still incipient. 

Treatment is of no avail, but absolute rest of the eyes from 
all attempts at near work, and the use of dark protection spec- 
tacles are important, so that, at the least, the advance of the dis- 
ease may not be encouraged. 

Malformations. 

Malformations of the Iris. — Heterophthalmos {erepo^, dif- 
ferent; ocp^aX/xo^). — This term indicates that the color of the 
iris in one eye is different from that in the other. 

Corectopia (noprj, the pupil; iuroTto^yOMt of position), or mal- 
position of the pupil. The pupil sometimes occupies a position 
farther from the center of the iris than normally. 

Polycoria (ttoXv?^ many; uoprj, the pupil). — Where there 
is more than one pupil. The supernumerary pupil may be sep- 
arated by only a small bridge from the normal pupil, or it may be 
situated very near the periphery of the iris. In neither case has 
it a special sphincter. 

Persistent Pupillary Membrane appears in the form of very 
fine threads stretched across the pupil. They cannot be mistaken 
for posterior synechise, as they are attached to the anterior sur- 
face of the iris some distance from the margin of the pupil. They 
do not interfere with the motions of the pupil, nor with vision. 

Colohoma ( ho\o/3 6? ^ maimed) and Irideremia {ipiS, ept^j^lay 
want of). — These two defects have been shown by Treacher 
Collins ^ to be due to a similar cause — in short, that they are 
different degrees of one and the same condition. Before the 
iris is formed in the fetus there exists, between the posterior sur- 
face of the cornea and the anterior capsule of the lens, the an- 
terior portion of the fibro-vascular sheath. This receives its 
blood-supply partly from the ciliary arteries, and partly from 
those in the posterior fibro-vascular sheath, prolonged round 
the sides of the lens to join it. The cornea, anterior fibro-vas- 
cular sheath, and lens lie in close contact with each other. The 
iris is developed by growing forwards from the margin of the 
anterior chamber, and in doing so has to insinuate itself be- 
tween the cornea and anterior fibro-vascular sheath on the one 
side and the lens on the other, pushing the prolongation from 
25 



298 DISEASES OF THE EYE. 

the posterior fibro-vascular sheath in front of it. The anterior 
fibro-vascular sheath subsequently becomes the pupillary mem- 
brane, of which portions sometimes persist (see above). If we 
suppose some abnormal adhesion to occur between the cornea, 
anterior fibro-vascular sheath, and lens-capsule, or some delay 
in their separation at the whole circumference of the future an- 
terior chamber, we can understand how a mechanical obstruction 
to any growth of the iris forwards would be introduced, resulting 
in complete absence of the iris, or irideremia. If the obstruction 
be confined to a portion only of the anterior chamber, the corre- 
sponding portion only of the iris will be prevented from growing 
forwards, and the result will be one or more congenital colo- 
bomata. Irideremia may be complete or partial. In the latter 
case it may be the inner circle only which is wanting, giving the 
pupil the appearance of dilatation with atropin. Where the en- 
tire iris is absent the ciliary processes can be seen all round. The 
condition may be binocular. The patients suffer chiefly from 
dazzling by light, from which either protection or stenopeic spec- 
tacles afford some relief. 

Malformations of the Chorioid. — Coloboma. — This "is a so- 
lution of continuity occurring always in the lower part of the 
chorioid, and usually associated with a similar defect in the 
iris. It may commence at the optic papilla, and involve the cili- 
ary body also, and even the crystalline lens may have a corre- 
sponding notch ; or it may not extend so far in either direction. 
The condition is recognized ophthalmoscopically by the white 
patch, due to exposure of the sclerotic where the chorioid is de- 
ficient. Sometimes the retina is absent over the defect in the 
chorioid, a circumstance which may be ascertained by the ar- 
rangement of the retinal vessels; but, even if it be present, its 
functions at that place are wanting, and a defect in the field of 
vision exists. Central vision is often normal. 

Albinismus, or the want of pigment in the chorioid and iris. 
This is usually accompanied by defective pigmentation of the 
hair of the body. The iris has a pink appearance, due to reflec- 
tion of light from its blood-vessels, and from those of the cho- 
rioid, and with the ophthalmoscope the latter vessels can be seen 
down to their finest branchings. The light which enters the 
eye, not being partially absorbed by pigment, causes the patient 
much dazzling, and high degrees of the condition are usually ac- 
companied by nystagmus. In childhood the albinismus and at- 



THE UVEAL TRACT. 



299 



tendant symptoms are more marked than later on, when some 
degree of pigmentation usually takes place. 

Much advantage may be derived in many of these cases by 




Fig. 93. 



Fig. 94. 



Fig. 95. 



Fig. 96. 



1 



the use of stenopeic spectacles, at least for near work. Any 
defect of refraction should be carefully corrected, in order to give 
the patients the best possible use of their eyes. 



300 



DISEASES OF THE EYE. 



Operations on the Iris. 

Iridectomy. — This is performed for optical purposes, as in 
zonular cataract, corneal opacities, or closed pupil; to reduce 
abnormally high intra-ocular tension, in primary and secondary 
glaucoma; and for the removal of tumors or foreign bodies in 
the iris. 

The instruments required are a spring speculum; a fixation 
forceps, with spring catch (Fig. 97) ; a lance-shaped iridectomy 




Fig. 97. 



knife (keratome) (Fig. 93), or a Graefe's cataract knife; a 
bent iris forceps (Fig. 94), or a Tyrrell's hook (Fig. 95) ; an 
iris scissors curved on the flat (Fig. 96), or a de Wecker's for- 
ceps-scissors; and a small spatula. 

The width of the colohoma depends a good deal on the length 
of the corneal incision, for it cannot be wider than the incision is 
long. Its depth depends on the proximity of this incision to the 
corneo-scleral margin. If a wide and very peripheral coloboma 






Fig. 98. 



Fig. 99. 



Fig. 100. 



be desired, the incision must be long, and must lie actually in 
the corneo-scleral margin ; the iris forceps being then introduced, 
a portion of the iris corresponding to the length of the incision 
may be seized, drawn out, and cut oflf, the blades of the scissors 
being applied parallel, and close to the incision, and by this means 
a coloboma, as at Fig. 98, is produced. An incision somewhat 
inside the corneal margin will give a pupil, as in Fig. 99. A 
narrow coloboma (Fig. 100) is obtained by a short corneal in- 
cision, which may be more or less peripheral as circumstances 



THE UVEAL TRACT. 301 

require; by takinp- u^ -^s little as possible of the iris in the 
forceps, or by using a Tyrrell's hook, instead of an iris 
forceps, for catching and drawing out the iris ; and by applying 
the blades of the scissors at right angles to the incision in the 
corneal margin. 

In glaucoma a wide and very peripheral coloboma is required. 
For optical purposes a narrow iridectomy is required, because 
with a wide coloboma the diffusion of light may be very trouble- 
some to the patient. 

The best position for an iridectomy for glaucoma is in the up- 
per quadrant of the iris, as there the subsequent dazzling by 
light and the disfigurement are least. But the position, by pref- 
erence, for an optical pupil is below and to the inside, being that 
most nearly in the direction of the axis of vision. If, however, 
this position be occupied by a corneal opacity, the coloboma 
should be made directly downwards ; or, if that place be ineligible, 
then downwards and outwards, or directly downwards, or di- 
rectly inwards. The upward positions are not satisfactory for 
optical pupils, owing to the overhanging of the upper lid; yet it 
often happens that we have no other choice. 

In the Performance of an Iridectomy the eye should be fixed 
with a forceps at a position on the same meridian as that in which 
the coloboma is to lie, but at the opposite side of the cornea, and 
close to the latter. The point of the lance-shaped knife is then 
to be entered almost perpendicularly to the surface of the cornea, 
and made to penetrate the latter. As soon as the point of the 
blade has entered the anterior chamber the handle of the knife 
is lowered, and the blade is passed on into the anterior chamber 
in a plane parallel to the surface of the iris, until the incision has 
attained the required length. The handle of the knife is now 
lowered still more, so as to bring the point of the blade almost 
in contact with the posterior surface of the cornea, in order to 
prevent any injury to the lens in the next motion. The knife is 
then very slowly withdrawn from the anterior chamber. At the 
same time the aqueous humor flows ofif, and the crystalline lens 
and iris come forwards. The fixation forceps is now taken 
over by the assistant, and the bent iris-forceps is passed closed 
into the anterior chamber, its points directed towards the po- 
sterior surface of the cornea, so as to avoid engaging them in 
the iris. When the pupillary margin has been reached, the for- 
ceps is opened as widely as the corneal incision will permit, 



302 DISEASES OF THE EYE. 

and the corresponding portion of the iris is seized and drawn 
out to its full extent through the corneal incision. With the 
scissors held in the other hand the exposed bit of iris is snipped 
off quite close to the corneal incision. Care should now be taken 
that the angles of the coloboma do not remain in the wound ; and 
if they are seen to do so, they must be reposed by stroking the 
region of the incision with a hard rubber spoon, or by pushing 
them into their places gently with the spatula. 

Iridotomy.— For description and use of this operation see 
chap xiii. 

References. 

* " Von Graefe's Archiv," xxxviii. 4. p. 93. *' Centralblatt fiir Augen- 
heilkunde," 1899, P- 40- " Graefe-Saemisch Handbook" (2d Ed.), vi. 

■"Trans. Ophth. Society, U. K.," vi., p. 170. 

■« Report of Committee of the Ophthal. Society of the United Kingdom 
on the " Relative Value of Simple Excision of the Eyeball, and the 
Operations which have been Substituted for it." — " Trans. Ophth. Soc, U. 
K.," 1898, p. 233. 

^ " Vooi Graefe's Archiv," xxvii. i. p. 331. 

* Ibidem, xxx. 3, p. 277. 

^Ibidem, xxxviii. i. p. I99- 

•^ " Bericht der ophthalmologischen Gesellschaft" Heidelberg, 1891, 
p. 44. 

' '' Trans. Ophth. Society, U. K.," xi. p. 55. 

^ " Von Graefe's Archiv," xliv. i. p. 164, 

' " Trans. Ophth. Society, U. K.," xiii. p. 128. 



CHAPTER XL 

THE MOTIONS OF THE PUPIL IN HEALTH AND 

DISEASE. 

The Size of the Pupil in Health depends chiefly on the intensity of 
the Hght to which the eye is exposed, contracting when Hght falls into 
the eye, and dilating in the shade. However defective vision may be, if 
quantitative perception of light remains, the reaction of the pupil as a 
rule takes place. 

There is no absolute Standard for tJie Physiological Sise of the Pupil. 
The latter varies in different healthy individuals, being in general smaller 
in elderly people than in youthful subjects; for with increasing age the 
energy of the sympathetic — the dilating nerve of the iris — is reduced, 
while there is sclerosis of the walls of the vessels of the iris and rigidity 
of its stroma. Hypermetropic eyes are apt to have small pupils, owing 
to the constant effort of accommodation ; while in myopia, for the con- 
verse reason, the pupils are wide. The diameter of the pupil when the 
accommodation is at rest has been found to vary between 2.z^4 and 5.82 
mm., giving an average diameter of 4.14 mm. 

Tange's ^ very careful investigations showed that the size of the pupil 
varies much in individuals ; that women have larger pupils than men ; 
that the physiological dimension of the pupil diminishes with the age; 
that the pupil is smaller in hypermetropia than in emmetropia ; that the 
size of the pupil becomes less as the hypermetropia increases ; that the 
physiological dimension of the pupil in mj'opia up to the twentieth year 
is greater than in emmetropia ; that with increasing age the differences 
in the dimensions of the physiological pupil in the different kinds of 
refraction becomes less, until beyond the fortieth year they are insignifi- 
cant ; that the color of the iris has no influence on the size of the 
pupil. 

Contraction of the Pupil. — Contraction to light is a reflex motion, the 
optic nerve being the afferent nerve, and the third nerve the efferent nerve 
innervating the sphincter pupillse. It has been shown by a high authority ^ 
that there are special afferent fibers in the optic nerve for the pupil-reflex, 
distinct from those for vision, and that it is possible to distinguish with 
the microscope these two kinds of nerve fibers from each other. 

The anatomical investigations of Meynert ^ have shown that between 
the corpora quadrigemina and the center for the third nerve run com- 
municating fibers (2 and 2, Fig. loi), which probably enable this reflex 
to take place. Owing to the semi-decussation of the fibers in the optic 
chiasma, the stimulus of light, when applied to one eye alone, passes up 

303 



304 DISEASES OF THE EYE. 

each tract with equal power to the corpora qiiadrigemina, and thence, by 
Meynert's fibers, to the nucleus of the third nerve (or rather to that 
portion of it which acts as a special center for the sphincter pupillae), and 
from that point down the myotic, or short ciliary, branches of this nerve 
to each ciliary ganglion, the ciliary nerves, and each sphincter iridis, 
causing -as active a contraction of the pupil in the non-illuminated eye 
(consensual contraction) as in its fellow. It is probable, however, * that, 
in addition to this method of bringing about consensual contraction of the 
pupil, there is a communication, direct or indirect, between the nuclei of 
the third nerve of each side capable of effecting it. In no other way 
can the fact be explained that consensual contraction of the pupil is 
maintained in cases of homonymous hemianopsia. If, for instance (Fig. 
loi), there be a lesion of the right tractus opticus giving rise to left 
hemianopsia, the nucleus of the left third nerve alone can be primarily 




Fig. ioi. — sN. Nucleus of third nerve, i. Connection between nuclei of 
third nerves. 2. Meynert's fibers. Q. Corpora quadrigemina. 
C. Chiasma. O. Optic nerve. P. Myotic fibers of third nerve. L. 
Seat of Lesion. Arrows show p^th of impulse in lesion of right 
tract at L. 

stimulated; but, as both pupils act, a communication between the nuclei 
of the third nerves must exist. Merkel ^ believes that there is a direct anas- 
tomosis between these nuclei. 

But it must be stated that there is a good deal of divergence of opinion 
as to the path by which the pupil reflex is brought about. Bechterew 
is of opinion that the centripetal pupillary fibers pass uncrossed from 
the chiasma directly to the gray matter surrounding the third ventricle, 
and thence backward to the pupillary nucleus of the oculo-motor nerve 
of their own sides respectively. Gudden made experiments which seemed 



THE PUPIL IN HEALTH AND DISEASE. 305 

to him to prove that the corpora quadrigemina had nothing to do with this 
path, and ascribed to the external geniculate body the part usually assigned 
to the corpora quadrigemina. Mendel's experiments ° would lead to the 
view that it is the ganglion habenulse which is the center for the pupillary 
reflex in animals, and in this he is largely supported by Darkschewitz, who 
holds that the pupillary fibers from the optic tract pass both into the 
pineal gland and the ganglion habenulse. According to Mendel, the reflex 
path would be : Optic nerve, optic tract, to the ganglion habenulae of the 
same side, thence by the posterior commissure to the nucleus of the third 
nerve, and thence to the ciliary nerves. 

Henschen ' inclines to think that the centripetal pupil-fibers are to be 
found in connection with the mesial root of the optic tract, and he excludes 
altogether the external geniculate body from their path. They would 
appear,, he says, to pierce the posterior section of the cerebral peduncle, 
and, with the other fibers of the mesial tract, to enter into relations 
rather with the internal geniculate body. 

Bernheimer's * researches prove to him that the pupil-fibers pass into 
the external geniculate body, from thence under the internal geniculate 
body, and into the substance of the anterior quadrigeminal body, and 
thence to the third-nerve nucleus in the aqueduct of Sylvius. Crossed and 
uncrossed fibers are contained in this course, and hence each sphincter 
nucleus is related to uncrossed fibers from the eye on the same side, and 
crossed fibers from the eye on the opposite side. He holds also that 
there is a more or less direct connection of the sphincter nuclei with 
each other, although he has not succeeded in demonstrating it ana- 
tomically. 

■ The reflex mobility of the pupil to light is tested most commonly for 
the purpose of deciding the existence or otherwise of posterior synechias 
The next most common object of the test, and the one with which we 
are here concerned, is to determine the sensitiveness to light of the 
retina or of the visual center. It affords generally a sufficient test of 
the presence or absence of quantitative perception of light; but it must 
be remembered that the latter function may be wanting in certain 
diseased states, and yet the pupil-reflex take place ; or the pupil-reflex 
may be wanting, and still perception of light be present. The test is 
best performed in diffuse daylight, with the patient's face directed 
towards the window, a distant object being looked at, and the eye which 
is not under examination being carefully excluded from the light. The 
surgeon then, having observed the size of the pupil to be examined, 
excludes the eye from light with his hand for some moments. On re- 
moving the excluding hand, a normally reacting pupil will be found to have 
become dilated ; and this dilatation, after an interval of about half a 
second, will be observed to give way to an extreme contraction, which is 
maintained only for a moment, and is then succeeded by a moderate dila- 
tation, and the pupil then again contracts somewhat, and so on, until, 
after some further minute oscillations, it comes to a standstill. The expla- 
nation for this phenomenon—which is termed hippus — is that each contrac- 
tion of the pupil, by diminishing the supply of light to the retina, contains in 
itself the cause of the succeeding dilatation ; and, for the converse reason, 
each dilatation sets a-going the succeeding contraction, until at last equilib- 
26 



3o6 DISEASES OF THE EYE. 

rium is attained. A comparison between the maximum of dilatation and 
maximum of contraction, along with the promptness and rapidity with 
which the contraction takes place, enables the observer to form an estimate 
of the activity of the pupil-reflex. In performing this test it is important 
that the patient's gaze should be fixed all through on a distant object — hence, 
unless where a mere trace of perception of light remains, the test used with 
the artificial light is not so reliable as that with daylight — so that the 
pupil-contraction which is associated with convergence or accommoda- 
tion (vide infra) may not vitiate the experiment. The danger of a 
vitiation of the experiment by the reflex dilatation from the skin (vide 
infra) caused by the excluding hand is insignificant in practice. The 
consensual reflex of the pupil, as well as the direct, should always be 
tested — one eye being alternately excluded and exposed, the motions of 
the pupil of the other eye are observed and compared with those of 
its fellow. 

In examining the pupils we have also to decide whether they are of 
equal size; and, in order to avoid error through posterior synechise, 
the comparison should be made, with both eyes open, successively in two 
very different brightnesses of light. Under normal conditions equality in 
size of the pupils will exist, not only with both eyes open, but also if one 
eye be shaded ; for the normal consensual pupil-reflex is equal to the 
direct reflex. If the pupils be found of different sizes, the least movable 
one is usually the pathological pupil, but this is a question often difficult 
to decide. Finally, it should be noted whether the direct pupil-reflex is 
similar in all respects in each eye. 

In addition to the stimulus of light, the pupil-contracting center is 
excited by, or simultaneously with, the effort of accommodation for near 
vision. The object of this contraction is to cut off rays falling on the 
peripheral portions of the lens, which latter are not curved in the change 
for accommodation to the same degree as is the center of the lens. This 
contraction, however, is much more intimately connected with conver- 
gence of the visual lines than with the effort of accommodation. It 
has been shown ^ that the contraction increases with the effort of 
accommodation, but not proportionately to the distance of the fixation 
point from the eye ; and ^^ that the pupils do not contract if accommoda- 
tion be effected without convergence, but that in convergence without 
accommodation contraction is observed. It has also been found that 
the contraction is proportional to the degree of convergence, and that 
in myopes of high degree contraction of the pupil takes place at the other 
side of the far point, where, of course, the accommodation does not come 
into play. 

Aubert ^^ thinks there is probably a common center for the three 
actions, convergence, accommodation, and pupil-contraction — a view sup- 
ported by Priestley Smith '^ ; and Hensen and Volckers " have found that 
in dogs, in the posterior part of the floor of the third ventricle, the 
nuclear centers for the branches to the ciliary muscle, the sphincter 
pupillae, and the rectus internus occur in close succession, and they think 
that this region may be regarded as the center assumed by Aubert. The 
existence of such a nuclear center has been placed beyond controversy by 
Eales' case ^* of paralysis of convergence and accommodation, and of the 



THE PUPIL IN HEALTH AND DISEASE. 307 

associated pupillary contraction. These three motions, then, are not 
dependent on each other, but are coeffects of one and the same cause — 
i. e., a stimulus applied to the center for convergence, accommodation, and 
pupil-contraction. 

In examining the mobility of the pupils in a given case the con- 
traction on convergence should not be omitted. If the patient be blind 
of both eyes, the observation can be made by calling on him to direct 
his eyes towards his own hand at about 12 inches' distance. If both 
accommodative contraction and light reflex are wanting, a lesion in the 
course of the centrifugal pupil fibers is indicated; while, if the light 
reaction alone is wanting, the lesion is in the course of the centripetal 
fibers. 

Dilatation of the Pupil. — The most reliable investigations '^ have dis- 
tinctly proved that there is no such muscle as the dilator pupillae. The 
dilatation of the pupil is in all probability largely the result of an inhibitory- 
action of the sympathetic, a view maintained also by Gaskell ^^ and Jessop." 
The posterior limiting membrane of the iris is its only structure which is 
not thrown into folds when the pupil dilates (Fuchs) ; and therefore there 
can be little doubt that it takes an active part in dilating the pupil, probably 
by reason of its elasticity. Yet, inasmuch as when the pupil is dilated 
from paralysis of the third nerve a further dilatation can be preduced by 
atropin, it is probable that some other, as yet unascertained, dilating 
power resides in the iris. The mydriatic, or long ciliary, nerves originating 
(Hensen and Volckers) in the front part of the floor of the aqueduct of 
Sylvius, pass to a region in the lower cervical and upper dorsal portion 
of the cord, called by Budge ^^ the ciliospinal center, and from thence pass 
out with the two first dorsal nerves, and by way of the rami communicate 
to the sympathetic in the neck, and thence to the cavernous plexus, Gas- 
serian ganglion, ophthalmic division of the fifth nerve, nasal branch of this 
division, ganglionic branch of this nerve, ciliary ganglion, there joined by 
more branches from the cavernous plexus, and from thence by the short 
ciliary nerves reach the eye. 

The dilating nerve fibers are probably of twofold nature, muscular 
and vasomotor. The experiments of Griinhagen,^^ Salkowski,^ Bonders 
and Hamer, "^ Stellwag, "^ and J. Arlt, jun.,"** indicate this; and that the 
center for each kind of fiber is different, though both are situated in 
the medulla oblongata, and their fibers probably run the same course 
to the eye. The center for the muscular fibers is called the oculo- 
pupillary center. That the vasomotor fibers have a decided and inde- 
pendent influence in dilating the pupil has been shown by Rouget,^* 
Schoeler,^^ and others. It is not certain what the mechanism of this 
influence may be, but it probably consists in a diminution in volume of 
the iris from anemia caused by contraction of the muscular coat of the 
vessels. 

Langley and Anderson ^° find that stimulation of the cervical sympathetic 
causes dilatation of the pupil before the vessels of the iris contract, and . 
that stimulation of the portion of the iris can produce a displacement of 
the pupil towards the side stimulated without relaxation of the sphincter. 
They assume, therefore, that there must be some radial contractile sub- 
stance in the iris, but in what form they do not say. 



308 DISEASES OF THE EYE. 

While light is the only stimulus capable of bringing about a reflex 
contraction of the pupil, the pupil-dilating center reacts to every sensitive 
stimulus — c. g., the prick of a pin or a pinch on the neck, galvanism ap- 
plied to the leg,^^ the tickling of a sensitive place in the region of the 
fifth nerve on the face/* etc., and Westphal ^^ observed dilatation on 
shouting loudly into the ear of a person under chloroform. Schiff and 
Foa ^^ found that in curarized dogs and cats a dilatation took place on 
the application of every stimulus, not necessarily painful, applied to the 
nerves of common sensation in any part of the body. Indeed, it is not 
necessary in the human subject that the stimulation should produce any 
sensation, for stimulation of the skin of the affected side in hemianesthesia, 
as also in sleep and in coma, will find response in dilatation of the pupil. 
The center for this reflex is probably in the medulla oblongata, ^^ but, in- 
asmuch as it takes place if the cervical sympathetic be divided,^^ it is evi- 
dent that all the dilating fibers do not run to the eye by way of the cer- 
vical sympathetic. Schiff ^^ thinks it probable that the Gasserian gan- 
glion receives pupil-dilating fibers from the sympathetic traversing the 
cavum tympani. 

Some psychical emotions produce dilatation of the pupil. The pupils 
of a cat in anger dilate, and those of a frightened child. In sleep, or 
when under the complete influence of an anesthetic, the pupils are con- 
tracted, for then all psychical and sensitive stimuli are reduced to a 
minimum. Facts authorize the conclusion that the medium dilatation 
of the pupil in the healthy state depends chiefly on the intensity of these 
stimuli, habitually transmitted through the sympathetic. If in any indi- 
vidual they be slight, his pupil is contracted ; if intense, it is dilated. 
Arndt ^* asserts that in delicate, nervous, excitable people the pupils are 
often much, and habitually, dilated. 

In addition to those already mentioned, there are causes for the dilata- 
tion of the pupil which can hardly be referred to simple reflex action, but 
which seem to be, like the contraction of the pupil on convergence of the 
visual lines, associated with those of other centers in the medulla oblon- 
gata, especially with those for respiration and uterine action. With every 
deep inspiration or expiration a considerable pupillary dilatation takes 
place, not identical with that slight dilatation occurring on each ordinary 
inspiration and depending on variation of blood pressure, but due ^^ to sim- 
ultaneous stimulation of the respiratory and pupil-dilating centers by 
retention of carbonic acid gas in the blood. Raehlmann and Witowski ^"^ 
have observed marked dilatation at the beginning of each labor pain, to be 
explained as an associated action of the neighboring centers for uterine 
movements and pupil-dilatation. 

Besides the normal pupillary motions described in the foregoing, and 
visible for the most part to the naked eye of the observer, there is a 
phenomenon of pupillary motion which is discoverable only by aid of a 
corneal microscope or loup, consisting in perpetual, but very minute and 
irregular, fluctuations in size of the pupil. This hippus has been aptly 
termed by Laqueur^^ the Unrest of the Pupil, and is due to the ever- 
varying sensitive and psychical reflexes which are thus constantly mani- 
festing their influences on the pupil. 

The Fifth Nerve has been held by some to have an influence over the 



THE PUPIL IN HEALTH AND DISEASE. 309 

motions of the iris similar to that of the sympathetic. This is, accord- 
ing to Leeser, a mistaken view ^* ; the effect on the pupil following section 
of the fifth within the cranium being due to paralysis of the sympathetic 
fibers contained in it, and not to the lesion of the proper fibers of the fifth 
nerve. But Spallita and Consiglio^** found, after removal of the superior 
cervical ganglion of the sympathetic, and when sufficient time for degen- 
eration had been allowed to elapse, that stimulation of the fifth nerve 
caused myosis. Others, *" again, have ascribed to the fifth nerve a direct 
influence over the contraction of the pupil ; but this is to be regarded as a 
reflex action merely, Merkel indeed having demonstrated^^ the existence 
of a direct fibrillar connection between the centers of the fifth and third 
nerves. 

Action of the Mydriatics on the Pupil. Atropin. — Inasmuch as a 
maximum mydriasis can only result from paralysis of the pupillary 
branches of the third nerve, combined with excitation of the pupillary 
branches of the sympathetic, and as atropin effects such a mydriasis, it 
is evident that it acts in the way indicated on these nerves.*^ A. von 
Graefe proved *^ that the aqueous humor of an eye into which atropin 
has been instilled acts as a mydriatic when applied to another eye. Du- 
boisin, Hyoscyamin, Scopolamin, and Daturin act similarly to atropin. 
Cocain mydriasis seems ** to be induced merely by a local irritation of the 
endings of the sympathetic in the iris, both of the vaso-constrictor fibers 
and of the pupil-inhibitory fibers. Strychnin and curare are not, strictly 
speaking, mydriatics, as they only indirectly affect the pupil ; the mydri- 
asis observed in poisoning by these drugs being, according to Schiff *^ 
and others, the result of the retention in the blood of carbonic acid 
gas. 

Action of the Myotics on the Pupil. Eserin (or PJiysostigmin). — This 
drug is in all respects a complete antagonist of atropin,*^ paralyzing the 
peripheral endings of the sympathetic in the iris, and stimulating the 
endings of the branch of the third nerve in the sphincter pupillse. Pilo- 
carpin and Muscarin act similarly, but not with the same energy. 
Nicotin applied to the eye is found to act like eserin.*^ Morphium has 
an antagonistic effect to atropin, both as regards the pupil and the general 
nervous system, and is employed in cases of poisoning by atropin (vide 
P- 257). 

Chloroform in the first or excitation stage of anesthesia, according to 
the investigations of Westphal,^ Budin,*** and Hirschberg,'° stimulates the 
pupil-dilating center, and in the second stage gradually reduces the excit- 
ability of this center, until, finally, it is completely paralyzed, so that no 
form of stimulation causes any dilatation. Following on this is a still 
further contraction to a pinhole pupil, due to stimulation of the pupil- 
contracting center. Should the inhalation of the anesthetic be continued 
longer, a dilatation of the pupil, often sudden, takes place, and this indi- 
cates paralysis of the nuclear pupil-contracting center, and the most serious 
consequences for the life of the patient. 

The Size of the Pupil in Disease. — Myosis may be caused by a diseased 
process irritating the pupil-contracting center or nerve-fibers (the Irrita- 
tion Myosis of Leeser), or by one causing paralysis of the pupil-dilating 
center or nerve-fibers (the Paralytic Myosis of Leeser), or by a com>^ 



3 10 DISEASES OF THE EYE. 

bination of both. Either cause alone would produce a medium myosis ; a 
combination of the two would give a maximum myosis. 

Irritation Myosis, according to Leeser, is not usually increased by the 
stimulus of light, nor on convergence of the visual axes, nor does it 
diminish in the shade. Mydriatics dilate such a pupil widely ; myotics 
contract it ad maximum. In paralytic myosis the pupil reacts well to light 
and on convergence, but does not dilate on application of sensitive or 
psychical stimuli, or with co-ordinated motions. Mydriatics dilate such 
a pupil only partially, while myotics contract it ad maximum. In maxi- 
mum myosis every reaction is wanting, strong mydriatics alone producing 
a medium dilatation. 

Irritation myosis is found — a. In the early stages, at least, of all in- 
flammatory affections of the brain and its meninges; in simple, tubercular, 
and cerebrospinal meningitis. When in these diseases the medium myosis 
gives place to mydriasis, the change is a serious prognostic sign,^^ indicat- 
ing the stage of depression with paralysis of the third nerve, b. In 
cerebral apoplexy the pupil is at first contracted, according to Berthold,^' 
who points out that this contraction is a diagnostic sign between apoplexy 
and embolism, in which latter the pupil is unaltered, c. In the early 
stages of intracranial tumors situated at the origin of the third nerve or 
in its course, d. At the beginning of an hysterical or of an epileptic 
attack.^' e. In tobacco amblyopia,^* probably from stimulation of the 
pupil-contracting center by the nicotin. f. In persons following certain 
trades, as the result of long-maintained effort of accommodation^" (watch- 
makers, jewelers, etc.), the pupil-contracting center being subject to an 
almost constant stimulus, g. As a reflex action in ciliary neurosis ; conse- 
quently, in many diseased conditions of those parts of the eye supplied by 
the fifth nerve. 

Paralytic myosis occurs in spinal lesions above the dorsal vertebrae — 
e.g., injuries and inflammations, especially of the chronic form. The 
contracted pupil occurring in gray degeneration of the posterior columns 
of the spinal cord has been long known as Spinal Myosis. In the simple 
form of this myosis the pupil has but a medium contraction, and reacts 
both to light and on convergence. This condition is found in the early 
stages alone, when the disease has attacked merely the cilio-spinal center, 
or higher up, as far as the medulla oblongata; later on, when Meynert's 
fibers become engaged, we have the Argyll Robertson pupil. The very 
minute pupil, often seen in tabes dorsalis, is probably due to secondary 
contraction of the sphincter pupillae.^*' 

Argyll Robertson was the first to point out" that in tabes dorsalis the 
pupil, although contracted, and responding to light by further contraction 
but slightly, or not at all, does become more contracted on convergence 
of the visual axes (or accommodation). He explained this phenomenon 
as being due to paralysis of the ciliospinal nerves, which he therefore 
regarded as the nerves supplying the sphincter iridis. But Raehlmann 
points out^^ that the myosis and the motor phenomenon are not directly 
connected; for it sometimes happens that pupils which do not react 
to light and do contract on convergence are noc habitually contracted, 
and may even be somewhat dilated. The two symptoms are no doubt 
often present together in tabes. The myosis is a sign, and an important 



THE PUPIL IN HEALTH AND DISEASE. 311 

one, of disease of the posterior columns ; while the defective reaction to 
light with retained contraction on convergence indicates disease at some 
distance from the spinal cord. It has been held by some that the seat 
of the disease, causing the Argyll Robertson pupil, is in Meynert's fibers 
(2 and 2, Fig. 100) connecting the corpora quadrigemina and the third 
nerve nuclei. But, as has been pointed out by Bevan Lewis,^^ while this 
explanation would answer were all instances of this symptom binocular, 
it cannot be the true one when, as we know, the symptom is sometimes 
unilateral; for the internuclear path (i, Fig. loi) between the nuclei of 
the two third nerves must exist in order to enable the consensual action 
of the pupils which takes place in lesions of one optic tract to be brought 
about. In the same way lesion of Meynert's fibers on one side would 
still permit of the pupillary reaction to light of each pupil. Bevan Lewis 
therefore concludes that the Argyll Robertson pupil is due to a nuclear 
lesion. Disease in Meynert's fibers (as also disease of the optic nerve) 
may be in direct connection with disease of the cord, Stilling having 
found"" fibers passing directly from the optic tract into the crus 
cerebri. 

Some authorities regard myosis as one of the earliest symptoms of 
tabes, while others do not. Raehlmann also thinks that, perception of light 
being present, if the pupils do not react to light, while they do con- 
tract on convergence, the symptom is usually one of serious central 
disease. 

Paralytic myosis is also found in general paralysis of the insane. In 
acute mania the pupil is usually much dilated ; and when this mydriasis 
is changed for myosis, approaching general paralysis may be prognosti- 
cated.^^ Myosis following on irritation mydriasis is also found in myelitis 
of the cervical portion of the cord. In bulbar paralysis, if paralytic myosis 
occurs, the disease is probably complicated with progressive muscular 
atrophy or with sclerosis of the brain and spinal cord."^ 

Hirschler states ^ that he has frequently noticed a contracted pupil in 
alcoholic amblyopia, due, probably, to an. affection of the medulla oblon- 
gata, possibly fatty degeneration. Myosis may also be due to paralysis 
of the cervical sympathetic, resulting from injury, from pressure of an 
aneurysm of the carotid, innominate, or aorta, or from pressure of enlarged 
lymphatic glands. In apoplexy of the pons Varolii myosis is present, but 
it is not yet certain whether it is an irritation myosis ®^ or a paralytic 
myosis.^^ 

Mydriasis may be caused by a diseased process giving rise to irritation 
of the pupil-dilating center or fibers, or by paralysis of the pupil-contract- 
ing center or fibers. 

The former is termed Irritation (or Spasmodic) Mydriasis, and, accord- 
ing to Leeser, is characterized by a moderately dilated pupil, contracting 
somewhat to light and on convergence, but not dilating on sensitive or 
psychical stimuli; easily dilated ad maximum by mydriatics, but with 
difficulty contracted ad maximum by myotics. The latter is called Paralytic 
Mydriasis, and in it there is a moderately dilated pupil, reacting to sensi- 
tive and psychical stimuli. The reaction to light and on convergence 
varies according to the seat of the lesion. If the lesion lie between the 



312 DISEASES OF THE EYE. 

iris and the pupil-contracting center, the direct and consensual reaction 
to light is wanting, as also the associated motion on convergence of the 
visual lines. But if the lesion lie between the retina and the pupil- 
contracting center, the direct contraction to light is wanting, while the 
consensual contraction and that on convergence are retained.*"* In either 
case the pupil can be dilated ad maximum by mydriatics, but not con- 
tracted more than to medium size by myotics. 

Irritation of the pupil-dilating center and paralysis of the pupil-con- 
tracting center existing simultaneously give rise to maximum mydriasis. 
In it there is absolute immobility to stimuli of all kinds, except to strong 
myotics, which may bring the pupil back to the normal size. 

Irritation Mydriasis occurs — a. In hyperemia of the cervical portion 
of the spinal cord and in spinal meningitis, b. In the early stages of new 
growths in the cervical portion of the cord. c. In cases of intracranial 
tumor and other diseases causing high intracranial pressure, according 
to Raehlmann, although Leeser points out that these may also give rise 
to paralytic mydriasis, d. In the spinal irritation of chlorotic or anemic 
people after severe illness, etc. e. As a premonitory sign of tabes dorsalis. 
r. in cases of intestinal worms, owing to the stimulation of the sensitive 
nerves of the bowel ; and sometimes in other forms of intestinal irritation. 
g. In psychical excitement — e.g., acute mania, melancholia, progressive 
paralysis of the insane (often then unilateral, with myosis in the other 
eye). 

Unilateral mydriasis occurring at short intervals, now in one eye and 
now in the other, is, according to Von Graefe," a premonitory sign of 
mental derangement. Von Graefe observes madness, in the form of manie 
des grandeurs, to come on some months after the occurrence of this 
symptom. 

Paralytic Mydriasis (Iridoplegia) may be due either to a paralysis of 
the pupil-contracting center or as the result of the stimulus not being 
conducted from the retina to that center. It may be found under the 
following circumstances : a. Sometimes in progressive paralysis, where 
at first there was myosis. b. In various diseased processes at the base 
of the brain affecting the nuclear center of the third nerve, c. In a late 
stage of thrombosis of the cavernous sinus. "^ d. In orbital processes which 
cause pressure on the ciliary nerves, e. In glaucoma, f. In cases of 
intra-ocular tumor? which have attained a certain size. 

In paralytic mydriasis, due to non-transmission of the stimulus of light 
to a healthy pupil-contracting center and nerves, contraction of the pupil 
will take place only on convergence of the visual lines. The same condi- 
tion of pupil will be found if the lesion lie in the course of Meynert's 
fibers, although vision may be normal. If the lesion lie in the center of 
vision, or in the course of the fibers connecting this center with the 
corpora quadrigemina, although absolute amaurosis exists, the reac- 
tion of the pupil to light will be perfect. Paralytic mydriasis, due to 
non-conduction of light stimulus, is found in most cases of optic 
atrophy. 

Bevan Lewis has pointed out "^ that the reflex dilatation on stimulating 
the skin is wanting in cases of general paralysis and of epilepsy to the 
extent of about 36 per cent, in women and 43 per cent, in men. 



THE PUPIL IN HEALTH AND DISEASE. 313 

Damsch has noticed ^^ a marked increase of the hippus of the pupil in 
certain diseased states — namely, multiple sclerosis, acute meningitis, 
apoplectic attacks followed by secondary tremor and spasms of the 
paralyzed muscles, and in neurasthenia. He is inclined to liken the hippus 
in these cases to the increase of the tendon reflexes, while immobility of 
the pupil would be the homologue of loss of tendon-reflex. Yet he does 
not think an exclusively reflex origin, for the exaggerated hippus can be 
adopted in these cases, as it continues to an abnormal degree even when 
all reflex irritation is avoided ; and consequently he concludes that an 
increase of the physiological hippus must be included as a cause. 

Forster " finds that in tabes dorsalis the oscillations of the pupil diminish 
in intensity, while the rhythm remains unaltered; but that in progressive 
paralysis the rhythm is lost. When the pupil has lost its power of reaction 
to light, the hippus still continues for a while. 



References. 

^ " Archiv f. Augenheilkunde," xlvi. i. p. 49. 

^ B. von Gudden, " Stitzungsber. d. Miinch. Ges. f. Morphol. u. Physiol.," 
1886, i. p. I. 

^ Vom Gehirn der Siiugethiere, " Strieker's Handbuch." Leipzig, 1870. 

* Leeser, " Die pupillarbewegung in Physiologischer und Pathologischer 
Beziehung," p. 14. Wiesbaden, 1881. 

^ " Graefe-Saemisch Handbuch," vol. i. 

"" " Neurolog. Centralbl," 1890, p. 184. 

'^ " Klin. u. Anatom. Beitrage z. Patholog. d. Gehirns," iii. p. ill. 

® " Von Graefe's Archiv," xlvii.," 1899, pt. i. p. i. and " Graefe-Saemisch 
Handbuch" (2d, ed.), vol. i. 

^ Adamiik and Woinow, " Archiv fiir Ophthalmologic," xvii, pt. I. 

'° E. H. Weber, " De Motu iridis." Lipsiae, 1851. 

^^ " Graefe und Saemisch Handbuch," ii. p. 669. 

^^ " Ophthal. Hosp. Rep.," vol. ix. p. 32. 

^^ " Arch. f. Ophthal.," xxiv. pt. p. 23. 

" " Trans. Ophthal. See./'' January 10, 1884. 

^^ Schwalbe, " Handbuch der Sinnesorgane " ; Eversbusch, '* Bericht d. 
Ophthal. Gesellsch.," 1884; Fuchs, "Graefe's Archiv," xxxi. pt. 3. p. 39; 
Jessop. " Proceed. Roy. Soc," 1886, p. 478. 

'" " Jour of Phys.," viii. i. p. 38. 

" " Proceed. Roy. Soc," 1886, p. 484. 

^^ " Ueber die Bewegungen der Iris," 1855. 

'' " Zeitschrift f. rat. Med.," xxviii., "Archiv. f. d. Gesam. Physiol.," 
Bd. liii. 

Ibid., xxix. p. 167. 
Nederl. Tijdschr. v. Geneesk.," 1864. 

''^" Ueber Atropin,'' " All. Wiener Med. Zeitung," 1872, p. 146. 

'' " Archiv fiir Ophthal.," xv. i. 

^* " Comptes rendus et Mem. de la Soc. de Biologic," 1856. 

'^^ " Experimentellc Beitrage zur Irisbegung": Inaug. Dis., Dorpat, 
1869. 



21 u 



314 DISEASES OF THE EYE. 

'^^ " Journal of Physiology," 1892, vol. xiii. No. 6. 

" Arndt " Griesenger's Archiv f. Psych.," ii. 

"* Hecker, " Tageblatt der 45 Versam. deutscher Naturforscher in 
Leipsig," 1872. 
^^ " Virchow's Archiv," xxvii. p. 409, 

"" " La piipilla come estesiometro," " L'Imparziale," 1874. 
^^ Salkowski, loc. cit. 

^' Vulpian, " Archiv de physiol, etc., de Brown-Sequard," Janvier, 
1874. 

^^ " Untersuchungen zur Naturlehre," x 1867, p. 423. 

^* " Archiv f. Psychiatric," ii. p. 589. 

'' Schiff, loc. cit. 

^""Archiv f. Physiologic," 1878, p. no. 

" " Klin. Monatsbl. f. Augenheilk.," December, 1887. 

^ Leeser, loc cit. pp. 46-48. 

^^ " Archivio de Ottalmologia," vol. i. 183. 

'^ Griinhagen, " Berl. Klin. Wochenschr.," 1866, No. 24; Rogow, 
" Zeitschr. f. rat. Med.," vol. xxix. p. 289. 

^^ " Graefe und Saemisch's Handbuch," i. p. 140. 

*' Hermann, " Lehrb. der exp. Toxicologic." 

*^ " Archiv f. Ophthal.," i. pt. i. p. 462, footnote. 

** Jessop, " Proceed. Roy. Soc," p. 441, 1885. 

*' " Pfluger's Archiv," 1871, p. 229. 

^' Harnack, " Arch f. exp. Pathol.," ii. p. 307 ; A. Weber, " Archiv f. 
Ophthal.," xxii. pt. 2. 

^' Rogow, " Zeitschrift f. rat. Med.," xxix. p. i ; Schur, " Zeitschrift f. 
rat. Med.," xxxi. p. 402. 

** " Virchow's Archiv," xxvii. p. 409. 

^® " Gazette des Hopitaux," 1874, p. 910. 

'" " Berl. Klin. Wochenschr.," 1876, p. 652. 

'^^ Leeser, loc. cit., p. 82. 

" " Bery. Klin. Wochenschr.," 1869, No. 39. 

°^ Wecker, " Graefe und Saemisch's Handbuch," iv. 

^' Hirschler, " Arch. f. Ophthal," xvii. pt. i. 

" Seiffert, " Allgem. Zeitschrift fiir Psychiatric," x, p. 544. 

^^ Hempel, " Archiv f. Ophthal.," xxii. pt. i. 

" " Edin. Med. Journal," xiv., 1869, p. 669, and xv., 1870, p. 487. 

°' Loc cit., p. 7. 

°'* " Brit. Med. Journal," April 25 and May 2, 1896. 

•^^ " Beilageheft zu Zehender's Monatsblatter," xvii. pp. 203-207. 

"Seiffert, loc. cit. 

"■' Leeser, loc. cit., p. 94. 

*^ " Archiv f. Ophthal.," xvii. pt. I. p. 229. 

*" Larcher, " Pathol, de la protub. Annulaire," deux, tirage, p. 54. 

"' Jiidel, " Berl. Klin. Wochensch.," 1872, No. 24. 

•^Heddaeus ("Archiv f. Ophthal." xxvii. p. 38) and Turner ("Royal 
London Ophthal. Hosp. Rep.." December, 1892) assume that the sphincter 
derives its nerve fibers from two nuclear centers — viz., from the special 
sphincter center, and also from the center for convergence (or accommo- 
dation). 



THE PUPIL IN HEALTH AND DISEASE. 315 

" " Archiv f. Ophthal.," iii. pt. 3. p. 350. 

^ Knapp, " Archiv f. Ophthal.," xiv. pt. i. p. 220. ' 

^^ " Brit. Med. Jonr.," April 25 and May 3, 1896. 

^° Neurolog. Centralbl," 1890, p. 258; also Zeminski, abstract in " An- 
nales d'Oculist.," March, 1894, p. 239. 

" Versammlung deutscher Naturf. u. Aerzte, Niirnberg, 1893 (" Deutsch. 
Med. Wochenschr.").. 



3i6 



DISEASES OF THE EYE. 



The three following tables, showing the action of the various 

been prepared for this 



TABLE 

The Mydriatics 





Atropin. 


SCOPOLAMIN. 


Solutions commonly used 


Atropin sulphate J^ to 2 per 


Scopolamin hydrobromate 




cent. Most commonly i 


t\j to \ per cent, (Accord- 




per cent. 


mg to some it is identical 
vs^ith hyoscin.) 


Effect on pupil 


Almost maximum mydria- 
sis ; light reaction lost ; in- 
creased by cocain. 


Same as atropin. 


Effect on accommodation 


Complete cycloplegia; begins 
later than mydriasis. 


Same as atropin. 


Action- 






begins in 


ro to 15 minutes 


7 to 10 minutes. 


reaches maximum in 


15 to 20 minutes. 


25 minutes. 


lasts from 


6 to 10 days. 


4 to 7 days. 


Effect on tension 


Doubtful in normal eyes ; 


Doubtful; tension not in- 




increases tension in eyes 


creased, according to 




predisposed to glaucoma. 


Raehlmann. 


Remarks 


Atropin possesses some 


Scopolamin is five times as 




disadvantages^ viz. 


powerful as atropin, but 




(a) Absorption through lac- 


its effect is of shorter 




rymal passages, causing 


duration. In \ per cent. 




poisonous symptoms (dry- 


solution it is not more 




ness and redness of throat 


poisonous than atropin, 




and face, faintness, stag- 


and less so than duboi- 




gering, delirium). 


sin. It is better borne by 




{b) Atropin infiltration, red- 


the conjunctiva than atro- 




ness and swelling of eye- 


pin. It should be used, 




lids and cheek. 


therefore — 




(c) Follicular conjunctivitis 


(a) Where atropin is not 
strong eftougn to break 




from frequent applica- 




tion. 


down posterior synechia". 




On account of its strong and 


(b) IVhere atroptn infiltra- 




/asking action it is the dest 


tion occurs. 




iuydriatic for protracted 






use, as in iritis. 





A few drugs not included in this table have been and are still used. Of these 
and are not to be recommended. Cocain as a mydriatic is not very useful when 
Holocain acts in the same way, without, however, affecting the cornea or circu- 



* These tables have been drawn up chiefly by the aid of a paper by Dr. H. Schultz. 

Archiv fiir Augen- 



THE PUPIL IN HEALTH AND DISEASE. 



317 



mydriatics, myotics, and local anesthetics on the pupil, etc., have 
book by Dr. Louis Werner ; 



(Pupil Dilators). 



HOMATROPIN. 



Homatropin hydro- 
bromate i per cent. 



Good mydriasis, but 
less than atropin 



Ephedrin. 



10 per cent. 



Good mydriasis 
light reactionre- 
tained. 



Mydrin. 



■EUPHTHALMIN. 



A mixture of homa-iEuphthalmin hj-drochlo- 
tropin and ephe- rate 5 per cent, 
drin : 

Homatropin o 01 

Ephedrin . i 

Water . . 10 



Mydriasis greater] Maximum mydriasis 
than either con-, light reaction lost, 
stituent; light re- 
action feeble. 



Marked, but not com- Little or no effect, 
plete cycloplegia. 



12 to 15 minutes. 
40 minutes. 
12 to 24 hours. 



8^ minates. 

30 to 60 minutes. 

5 to 20 hours. 



Not so liable to raise Little or none, 
tension as atropin 



Homatropin is less 
powerful and less 
poisonous than atro- 
pin. On account of 
its action on accom- 
modation, and the 
short duration of its 
effect, it is the best 
jnydriatic for esti- 
mating errors of re- 
fraction. Its effect 
is increased by the 
addition of cocain. 



It does not act 

quickly enough 
for use in prac- 
tice as an aid 
to ophthalmo- 
scopic diagnosis 
and i' more use- 
ful when com- 
bined with ho- 
matropin. 



None. 



8^ minutes. 

30 to 40 minutes. 

4 to 6 hours. 



Themydriasisbeing 
greater and of 
shorter duration 
than with either 
constituent, and 
having no action 
on the accommo- 
dation, it is well 
suited for ophthal- 
moscopic diagnosis 



Less than homatropin. 



10 to 15 minutes. 
60 to 80 minutes. 
5 to 7 hours. 



None. 



Although a little slower 
than homatropin, it is 
as good a mydriatic, 
but has the advantage 
of acting on the accom- 
modation only in a 
slight degree, and its 
effects pass off much 
more quickl}-. It is 
also morepowerfulthan 
mydrin, and therefore 
the best ynydriatic for 
ophthalmoscopic diag- 
nosis. It possesses no 
irritating or toxic ef- 
fects, and does not 
injure the corneal epi- 
thelium. 



daturin is the same as atropin. Hyoscyanin and duboisin are very active poisons 
employed alone, butit facilitatesabsorptibn, andincreasestheeffect of 'othermydriatics 
lation, like cocain. 



"Die alteren und neuernMydriatica, Mioticaund Anasthetica inder Augenheilkunde,'' 
heilk. Bd. xl , S. 125. 



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319 



CHAPTER XII. 
GLAUCOMA.* 

The chief and essential symptom of this disease is Increased 
Intra-ocular Tension — increased hardness of the eyeball — due to 
overfuUness of the globe. 

There is Primary Glaucoma and Secondary Glaucoma. 

In primary glaucoma, the increased tension comes on without 
any previous recognizable disease of the eye; and it is with 
it we have mainly to do in this chapter. 

In secondary glaucoma, the increased tension comes on in 
consequence of obvious antecedent disease in the eye. 

Primary Glaucoma. 

Primary glaucoma is almost invariably a binocular disease, al- 
though it does not always attack each eye simultaneously, in- 
deed it is more common for the disease to appear in the eyes with 
an interval of months or longer. 

Of primary glaucoma there are two great kinds — the Non- 
inflammatory, Non-congestive, or Chronic Glaucoma ; and the 
Inflammatory, Congestive, or more or less Acute Glaucoma. In 
using the term inflammatory here it is not implied that acute 
glaucoma is an inflammation in the strict pathological sense of 
the term, or, if so, to but a slight extent. The term is employed 
rather on account of some symptoms which are present (pain, 
redness of the eyeball, lacrimation), and which we are wont 
to see with inflammations of the eye — symptoms which are want- 
ing in chronic glaucoma. 

Increased intra-ocular tension, then, is the chief and essential 
symptom of glaucoma, whatever form of it may come before 
us ; although this increased tension may not be present in the 
same degree, or, indeed, at all, at every time. 

* From -yTiamo^, sea-green. The name was given to the disease by the 
old writers, on account of the greenish reflection obtained from the pupil 
in some cases. But this greenish reflection is seen in other diseased condi- 
tions, and therefore is not characteristic of glaucoma. 

320 



GLAUCOMA. 321 

If the surgeon place the tips of his index fingers close to- 
gether on a normal eyeball, and make gentle pressure with them 
alternately, he will observe that the eyeball pits slightly on this 
pressure, and that a sensation of fluctuation is given to the fin- 
gers. The amount of this pitting or fluctuation varies according 
to the degree to which the eyeball is filled with its humors, and 
also, to some extent, according to the thickness of the sclerotic 
coat, and is not precisely the same in every normal eye. The 
glaucomatous eyeball is felt to be more resistant — to be harder 
— than the normal globe. 

But there are normal eyes which have a tension below the 
average normal tension, and others which have a tension some- 
what above the average normal tension, and in eyes of the latter 
class it is occasionally diflicult to decide whether or not the 
tension is abnormally high, especially if there happen to be 
symptoms which might be due. to high tension. If it be a ques- 
tion of one eye only, then a comparison of its tension with that 
of its fellow decides the matter, for the physiological tension 
is always the same in each eye. 

Some clinical experience is necessary before the surgeon can 
appreciate by palpation those degrees of tension which are just 
above or just below the normal ; and no other method is equally 
satisfactory. Tonometers have indeed been invented for the 
purpose, but for ordinary use the educated fingers are to be 
preferred. 

For the purposes of clinical notation Sir W. Bowman sug- 
gested some signs, which have been very generally adopted. 
Normal tension he indicated by the letter T, slight increase 
of tension by T -f i, still higher tension by T + 2, while T -}- 3 
indicates stony hardness of the eyeball. In the same way dimin- 
ished tension is T— i, T — 2, and T — 3. T+ ? and T— ? 
indicate that it is doubtful whether the tension be slightly above 
or below the normal. But the application of these symbols to the 
varying degrees of tension depends very much upon the ob- 
server. " T -|- 2," for instance, will not always convey precisely 
the same idea to every surgeon. 

The other symptoms of glaucoma are largely due to the in- 
creased tension; but in chronic glaucoma there are by no means 
so many symptoms as in acute glaucoma. Let us now discuss 
these two great forms of primary glaucoma separately. And 
first as to Chronic, or Non- Inflammatory, Glaucoma (also 

27 



322 DISEASES OF THE EYE. 

known as Simple Glaucoma, as Simple Chronic Glaucoma, and as 
Chronic Non-Congestive Glaucoma). 

Symptoms. — The tension is raised. Sometimes the eye is very 
hard (T + 2, or more), and again it may be but slightly raised 
(T+i). Even in one and the same eye the tension usually 
varies, and may be at one time too high and at another almost, 
or quite, normal. 

The external appearance of the eye is usually quite normal, 
and the pupil reacts well to light. The anterior chamber is 
sometimes a little shallow. 

On examination with the ophthalmoscope the optic papilla is 
found to be cupped. The optic disc, being the weakest part of 
the ocular a\ 11 i IIk fiist place to give way to the high tension; 




of 



Fig. 102. — (Ed. Jaegef), sc, Sclerotic; ch, Chorioid; r, Retina; of, Optic 
nerve ; ca, Intervaginal space ; v, External sheath of the optic nerve ; 
E, Excavation of the papilla ; m. Margin of the excavation ; Ic, Lamina 
cribrosa. 

and after a time it becomes depressed or cupped, the excavation 
being often deeper than the outer surface of the sclerotic, and the 
lamina cribrosa being pushed back (Fig. 102). This cupping of 
the papilla is a most important sign of glaucoma, and differs es- 
sentially in appearance from the physiological cupping (vide 
p. 88), inasmuch as it occupies the entire area of the papilla, and 
has steep, not shelving, sides. As shown in Fig. 102, the walls 
of the excavation are often hollowed out, and the ophthalmo- 
scopic effect of this is to give to the retinal vessels the appearance 
of being broken off at the margin of the papilla (Fig. 103), where 
they pass round the overhanging edge of the excavation, and 
become hidden by it, while on the floor of the excavation they 
reappear. 



GLAUCOMA. 



323 



The presence of an excavation may be recognized ophthal- 
moscopically, in the examination by the indirect method, by 
means of lateral motions of the convex lens. It will be then 
seen that, while the whole fundus seems to move along with 
the motion of the lens, the floor of the excavation apparently 
moves in the same direction, but at a slower rate. This parallax 
is the more marked the deeper the excavation. The phenomenon 
is explained by the accompanying figure (Fig. 104). If o 
be the optical center of the lens being used in the examination, 
and b and a two points lying one behind the other, the inverted 




.^^ 



Fig. 103. — (Ed. Jaeger), a, Arteries; v, Veins; m, Margin of disc; k. Bend- 
ing of vessels at margin of the disc; Vp, Vessels on the floor of the 
excavation ; z, Glaucomatous ring. 



images of these points will be situated at h' and a'. The line 
a' h' lies in the visual line of the observer; and if the lens be 
moved upward a very little, so that the optical center comes to 0', 
the inverted images of h and a will be removed to h^ and a^. If 
the observer has not altered his point of view, it will seem to 
him that the point h has made a more extensive motion than the 
point a; or that it has moved more rapidly than a, and has glided 
between a and the observer. Short and rapid motions of the 
lens from side to side, or from above downwards, will best show 
the parallax. 



324 DISEASES OF THE EYE. 

In the upright image, the existence of an excavation may 
be ascertained by observing that a lens of a different power is 
required in order to obtain a clear image of the margin of the 
papilla and of its floor.*- The depth of the excavation may be 
estimated by noting the difference between these two lenses — 
e. g., if the general fundus of the patient be emmetropic, and 
the emmetropic observer require 3 D to see the floor of the ex- 
cavation, the depth of the latter is about i mm., and in the same 
proportion up to 10 D. 

Besides being cupped, the optic papilla becomes atrophied from 
the pressure, and its consequent pallor serves to aid the diagnosis 
between this and a physiological excavation. 

But we meet with cases in which the optic disc is cupped and 




Fig. 104. 

pale, and in which increased tension is either not present at the time 
of the examination, or is so slight as to be doubtful. And here the 
diagnosis between glaucoma and primary atrophy of the optic 
nerve with cupping of the disc is one of the most difficult to be 
met with. The examination of the field of vision may not al- 
ways assist, for in each of these diseases it is liable to be con- 
tracted ; but if the contraction occur with re-entering angles, it 
points to primary atrophy, for this form of field is not found 
with glaucoma. The effect of a myotic on the intra-ocular pres- 
sure may aid the diagnosis, for it would not materially in- 
fluence normal tension, while it would reduce abnormally high 
tension. 

The color sense usually remains normal in glaucoma until 



GLAUCOMA. 325 

a late stage, while in primary optic atrophy it is defective at 
an early stage. Again, if slight pressure with the tip of the 
surgeon's finger produces arterial pulsation at the optic papilla, 
it is suggestive of glaucoma, for in a normal eye considerable 
pressure is needed to produce this effect. 

Spontaneous pulsation of the arteries on the optic papilla may 
be often noted in glaucoma, because blood can only be forced 
into these vessels by a pressure greater than that opposed to it. 
In the eye with normal tension there is no arterial pulsation, — 
and slight pressure with the tip of the finger would not bring it 
on, — for the tension of the coats of the vessels is greater than the 
intra-ocular tension ; and, therefore, the blood passes on in a 
continuous stream. But in the decidedly glaucomatous eye the 
intra-ocular tension opposes so great an obstacle to the arterial 
flow that at the systole alone can it make its way through. 

Arterial pulsation also occurs, although rarely, in exophthalmic 
goiter (see chap, xviii.) ; and it occurs where the pressure in 
the arteries themselves is low (weak heart's action, aortic re- 
gurgitation, etc.), although that in the vitreous chamber be 
normal. 

Around the margin of the glaucomatous excavation, especially 
in chronic glaucoma, one usually sees the whitish appearance, 
termed the glaucomatous ring (Fig. 103), which is said to be due 
to atrophy of the chorioid from pressure. 

The acuteness of central vision is diminished, and increasing 
dimness of sight is the only symptom of which the patient com- 
plains in chronic simple glaucoma. 

Besides this, the field of vision becomes contracted in conse- 
quence of interruption to conduction in the retinal nerve-fibers 
from pressure on them at the miargin of the depressed optic pa- 
pilla. This contraction of the field must always be carefully ex- 
amined for with the perimeter in eight or ten meridians. A 
hurried or careless examination of the field is worse than useless, 
for it may lead astray in the diagnosis and prognosis. The con- 
traction commences at the nasal side, as a rule, while at the same 
time central vision is lowered, and later on the temporal portion 
of the field becomes contracted, and gradually absolute blindness 
is brought about. 

The progress of the disease is extremely slow and insidious, 
extending often over several years, and ends in total blindness 
if untreated. It usually attacks both eyes, but generally one of 



326 DISEASES OF THE EYE. 

them long before its fellow. Sometimes chronic simple glau- 
coma, after a time, takes on the acute or the subacute form. 

Acute, or Inflammatory, Glaucoma (also called Acute Con- 
gestive Glaucoma). — In this form the increase of tension is 
always very marked. In addition to this there are the following 
symptoms : 

Diminished Depth of the Anterior Chamber, from pushing for- 
wards of the lens and iris. 

Diminution of the Refracting Power of the Eye, by reason of 
the nearer approach of the latter to a globular shape. 

Diminution of the Amplitude of Accommodation, and Anes- 
thesia of the Cornea, owing to pressure on the ciliary nerves as 
they pass along the inner surface of the sclerotic. 

Opacity of the Cornea, giving its surface a peculiar steamy 
or breathed-on appearance, due to edema of the corneal tissue 
and epithelium, by infiltration into them of the intra-ocular fluids 
from high tension. A similar opacity of the cornea is sometimes 
seen in iritis and iridochorioiditis, and in interstitial keratitis. 

Indistinctness of the Pattern of the Iris, similarly due to edema. 

Opacity of the Aqueous and Vitreous Humors. 

Dilatation and Immobility of the Pupil, the result, according 
to some, of paralysis of the ciliary nerves, but, according to 
others, of anemia of the iris from pressure on its vessels. The 
pupil is oval, with its long axis vertical. 

The Episcleral Veins are large and tortuous, owing to the 
pressure on the vasse vorticosse preventing the discharge by those 
channels of the chorioidal venous blood, which must then pass 
off by the anterior ciliary veins. 

Subjective Appearances of Light and Color, and colored halos 
or rainbows around lamps and candles (iridescent vision), are 
complained of. Similar appearances are sometimes experienced 
by persons suffering from chronic conjunctivitis. 

Pain is a very marked symptom of acute glaucoma, both in 
the eye, and radiating over the corresponding side of the head. 
This pain is often very violent. 

Vision is greatly affected, and the field of vision will be found 
contracted, in cases of some standing. 

The Optic Papilla, when the media are sufficiently clear to ad- 
mit of its being examined, is seen to be cupped if the disease have 
continued sufficiently long to bring about this change. 

In acute glaucoma we recognize certain Premonitory Symp- 



GLAUCOMA. 327 

toms — viz., sudden diminution of the amplitude of accommoda- 
tion, evidenced by the rapid onset or increase of presbyopia, and 
the consequent necessity for higher + glasses for near work ; and 
the occasional appearance of colored halos around the flames of 
lamps or candles, with attacks of fogginess of the general vision. 
The duration of one of these foggy attacks may be from a few 
minutes to several hours. Such attacks are apt to occur after a 
sleepless night, or after a meal, and are sometimes accompanied 
by peri-orbital pains. Slight opacity of the aqueous humor, and 
sluggishness of the pupil, with some dilatation, are present dur- 
ing an attack ; but the eye afterwards returns to its normal condi- 
tion, and remains so for weeks or months, until another similar 
attack comes on. Such a premonitory stage may last a year or 
longer, but cases also occur in which there is no premonitory 
stage. 

The most favorable time for operative interference is during 
this prodromal stage. It can then be performed with technical 
accuracy in an eye free from congestion and with a normally 
deep anterior chamber. There is, too, as yet no loss of sight, 
nor any degeneration of the tissues of the eyeball. The diffi- 
culty is to induce patients to consent to operation at this period. 

The onset of the True Glaiiconiatous Attack is usually at 
night. It is accompanied by violent pain radiating through the 
head from the eye, by pericorneal injection, chemosis, and lacri- 
mation. The aqueous humor is cloudy, the anterior chamber 
shallow, the iris discolored, and the pupil dilated to medium size 
and of oval shape, the cornea steamy and anesthetic. The pa- 
tient frequently complains of subjective sensations of light, and 
vision is very defective, or may be quite wanting. Vomiting 
very frequently accompanies acute glaucoma, and has often led 
to errors of diagnosis, the patient's ailment having been taken to 
be a gastric disease, while the ocular symptoms were regarded as 
mere coincidences, such as a cold in the eye, neuralgia, etc. 

An attack like that just described may, to a great extent, pass 
away in the course of a few days, but a complete remission of all 
the symptoms does not take place. Some defect of central vision 
is left, or, it may be, some slight peripheral defect in the field of 
vision ; the tension does not become quite normal again, and the 
pupillary motions remain slightly sluggish. Another acute at- 
tack of glaucoma comes on in the course of some weeks or 
months, and it, too, may pass away, leaving the eye in a still worse 



328 DISEASES OF THE EYE. 

condition than it found it. The attacks gradually become more 
frequent; and if in the intervals the eye be examined the cornea 
and vitreous humor will be found more or less opaque, the optic 
papilla cupped, and an arterial pulsation may be discovered. 
Finally, there is no remission from the attack, the violent glauco- 
matous symptoms become permanent, and all vision is forever 
destroyed. 

Even when vision has been destroyed the high tension con- 
tinues, and gradually produces disorganization of the tissues of 
the eyeball (glaucomatous degeneration). The iris becomes 
atrophied, the lens becomes opaque, and the cornea frequently 
ulcerates, while hemorrhages are apt to occur in the anterior 
chamber. In time the excessive intra-ocular tension causes 
staphylomatous bulging of the sclerotic in the ciliary region, or 
further back; and, finally, such eyes may become the subjects of 
acute purulent chorioiditis, and end in phthisis bulbi. 

Acute glaucoma almost always comes on in both eyes, either at 
the same time, or with an interval, it may be of weeks, or of 
months. 

The reason why there is so marked a difference between the 
symptoms and course of chronic and of acute glaucoma is prob- 
ably that in the former the increase of tension is very gradual, 
and therefore the eye gradually becomes accustomed to it ; while 
in acute glaucoma the increase is rapid or sudden, and the circu- 
lation of the eye has not time to accommodate itself to the new 
state of things. 

Glaucoma Fuhninans is the name given by von Graefe to a 
form of the disease which is more acute than the ordinary acute 
glaucoma just described. It has no premonitory stage, and, com- 
ing on with all the symptoms of acute glaucoma greatly exag- 
gerated, does not remit, and causes complete permanent destruc- 
tion of vision in the course of a few hours. It is a rare form. 

Subacute Glaucoma. — This form differs from acute glaucoma 
in that its premonitory stage merges gradually into the actual 
disease without the occurrence of an acute attack. The eye 
gradually becomes hard, the pupil dilated, the anterior chamber 
shallow, the aqueous humor opaque; while the cornea is 
'•' steamy " and anesthetic, and the episcleral veins are distended. 
Ophthalmoscopically the cupped disc and pulsating arteries may 
be seen, when the opacities of the media permit. Vision sinks, 
and the field is. contracted towards its nasal side. The progress 



GLAUCOMA. 329 

of the disease is very slow ; and in its course attacks of ciliary 
neuralgia, with greater increase of the tension, greater opacity 
of the aqueous humor, increase of the corneal opacity and anes- 
thesia, and further dimness of vision, are experienced. These 




Fig. 105. — Diagrammatic representation of normal condition. I. Angle 
of anterior chamber, and ligamentum pectinatum. s. Canal of 
Schlemm. p. Venous plexus of Leber. 

attacks pass off again in the course of a few days or hours, leav- 
ing the eye harder and blinder than before. The subacute glau- 
coma sometimes takes on the acute form. It is liable to bring 




Fig. 106. — Diagrammatic representation of glaucomatous condition. /'. 
Obliterated angle of anterior chamber. 

about the same glaucomatous degeneration of the eye as does the 
latter. 

Etiology of Glaucoma. — Glaucoma is a disease of advanced 
life, occurring most usually after fifty years of age, and rarely 
28 



330 DISEASES OF THE EYE, 

under the thirtieth year. It is not peculiar, or more common to 
any one constitution or temperament. Anxiety, sorrow, and in- 
fluences in general which depress the spirits have often been 
noticed to precede the onset of acute glaucoma. 

As regards the Pathology of Glaucoma the theory which of 
late years has obtained most acceptation owes its origin to Max 
Knies ^ and Adolf Weber ^ and is known as the Retention 
Theory. These observers ascertained that in glaucomatous eyes 
the periphery of the iris lies in contact with the periphery of the 
cornea (Figs. 105 and to6) in the region of the canal of 
Schlemm, venous plexus, and ligamentum pectinatum. But this 
region and these tissues had previously been proved by Leber ^ 
to be the ways of exit of the efifete intra-ocular fluids, which flow 
to that point from the posterior part of the aqueous chamber 
through the pupil. Weber and Knies concluded, therefore, that 
the blocking of these passages, from the close application of the 
iris, caused glaucoma by preventing the effete fluids from escap- 
ing : and that thus the disease was one of retention rather than of 
hypersecretion, as it had previously been considered to be. 
Weber believed that swelling of the ciliary processes, from one 
cause or another, pushes the periphery of the iris forwards, and 
gives the starting point for glaucoma. 

Brailey * to a certain extent adopts this view of Weber, but re- 
gards ^ a chronic inflammation of the ciliary processes and periph- 
ery of the iris, with distention of the blood-vessels of these 
parts, to be the chief factor in the earliest history of the disease. 

Max Knies ^ also regarded glaucoma as an iridocyclitis, which, 
owing to varying intensity, produces the different forms of the 
disease. 

Priestley Smith ^ adopts the retention theory, and holds that 
the main predisposing cause of primary glaucoma is an insuffi- 
cient space between the margin of the lens and the structures 
which surround it ; and he attributes the greater liability of 
elderly people to the progressive increase in the size of the lens 
which he has proved ^ to occur as life advances. In eyes in 
which the circumlental space is insufficient, by reason either of 
the original structure of the eye — and small eyeballs, as Priestley 
Smith has shown, are specially liable to primary glaucoma, a fact 
often demonstrated by the small size of the cornea in the eyes at- 
tacked — or of the enlargement of the lens, any condition which 
tends to overfill the veins of the head and uveal tract may initiate 



GLAUCOMA. 331 

an attack of acute glaucoma as follows : An increase in the 
amount of blood in the uveal tract must be compensated by the 
expulsion of some other fluid from the eye; consequently, the 
aqueous humor filters out more rapidly than is normal at the 
angle of the anterior chamber. As the contents of the chamber 
diminish, the lens and iris move forwards towards the cornea. 
Now in the normal eye, and especially in the youthful eye, this 
compensation is effected without danger to the angle of the an- 
terior chamber, because the lens is comparatively small, the cir- 
cumlental space large, and the anterior chamber deep. But when 
the lens and ciliary processes are already in close relation to each 
other, and the anterior chamber already shallow, then any in- 
creased fullness of the uveal tract involves danger to the angle 
of the chamber. The turgid ciliary processes find insufficient 
space for their expansion; they are carried forwards together 
with the lens, and, pressing upon the base of the iris, lock up the 
angle of the anterior chamber. Thereupon, the further escape 
of fluid being impossible, high tension of the eyeball is estab- 
lished. According to this explanation, then, the high tension is 
due to impeded escape of the intra-ocular fluid, and depends, pri- 
marily, rather upon an increase in the amount of blood in the eye, 
than on an excess of the intra-ocular fluid. Priestley Smith con- 
siders that, in chronic simple glaucoma, the predisposing causes 
are the same as in acute glaucoma ; but that in the former, the 
vascular disturbance being gradual and slight, the vessels adapt 
themselves to the slowly increasing pressure, and the angle of 
the anterior chamber is more or less compressed, but not tightly 
closed. 

Von Graefe ^ believed that a serous chorioiditis lay at the root 
of the disease, which he thought was caused by exudation of 
serous fluid into the vitreous humor ; while Bonders, ^° von Hippel 
and Griinhagen/^ and others held that irritation of the fifth pair 
of nerves, governing the secretion of the intra-ocular fluids, gave 
rise to hypersecretion of those fluids. 

Others, again, held that changes in the sclerotic, rendering it 
rigid, and leading to some shrinking of it, caused the increased 
intra-ocular tension. 

Laqueur ^^ believes that some such sclerotic changes produce 
obstruction of the posterior w^ays of exit of the intra-ocular lym- 
phatics — namely, those which pass out with the four vasas vor- 
ticose — and that glaucoma depends largely upon this obstruction. 



332 DISEASES OF THE EYE. 

But these theories are now obsolete, and I mention them merely 
as being of historical interest. 

Treatment. — The performance of an iridectomy is the means 
discovered by von Graefe/^ in the year 1857, ^oi* ^^^ cure of glau- 
coma, a disease which had hitherto been incurable. This meas- 
ure held an undisputed position as the sovereign remedy for the 
disease until a few years ago, and even yet has not suffered much 
from the competition of the operation of sclerotomy. 

To insure the success of an iridectomy for glaucoma, so far 
as possible, it is necessary ( i ) that the incision should be periph- 
eral — i. e., as far back in the corneo-sclerotic margin as is 
compatible with the introduction of the knife into the anterior 
chamber, and with the avoidance of injury to the ciliary body ; 
(2) that the portion of iris removed should be wide — i. e., involv- 
ing about one-fifth of the circumference of the iris (see Fig. 98). 

It is, moreover, important to withdraw the knife very slowly 
from the anterior chamber, when the corneo-scleral section is 
complete, in order that the aqueous humor may flow ofif gradu- 
ally, lest an intra-ocular hemorrhage from the sudden reduction 
of tension should occur. The portion of iris should be most 
carefully abscised, so that no tag of it may remain in the wound, 
and become caught in the cicatrix in the course of healing. Such 
an occurrence is apt to produce a cystoid cicatrix, which may at 
a later period become the starting-point of irritation, and even of 
serious inflammation. Some operators prefer von Graefe's cata- 
ract knife for the performance of the operation, but the ordinary 
lance-shaped iridectomy knife is the instrument usually employed. 
For the purpose of reducing the intra-ocular tension it matters 
nothing what region of the iris be abscised ; but, as a rule, the 
upper quadrant is to be preferred, for there the resulting colo- 
boma, being covered to a great extent by the upper lid, will give 
rise to less diffusion of light than in any other position. 

Immediately after the operation, palpation of the eyeball 
should show a marked diminution of tension. When this is not 
so the prognosis is unfavorable. Should an increase of tension 
occur on the day after the operation, it is of no consequence, as it 
passes off again in the course of the next few succeeding days. 
Until then the anterior chamber will not be restored, and we see 
cases where the anterior chamber does not appear for a week or 
more. The bandage should be worn until the anterior chamber 
is completely restored. It is desirable to perform the operation 



GLAUCOMA. 333 

with general anesthesia, to secure technical accuracy. The pain 
for some time after the operation is considerable, and should be 
relieved by a h}'podermic injection of morphia in the correspond- 
ing temple. 

Very occasionally, immediately after iridectomy, although the 
operation may have been faultlessly performed, the case takes 
what we call a malignant course. In these cases the lens seems 
to be violently pushed forwards, blocking the wound, obliterating 
the angle of the anterior chamber, and preventing any fluid from 
escaping from the eye, so that very soon it is as hard, or harder, 
than before. This complication seems to be caused by the re- 
tention of fluid behind the lens, and is more likely to occur in cases 
of chronic simple glaucoma than in the acute forms of the disease. 

In chronic simple glaucoma, if any cataract be present as 
well, it very often develops rapidly after the iridectomy; and in 
nearly all cases a certain amount of disturbance of vision results 
from astigmatism produced by the operation. All these risks and 
disadvantages must be faced by the patient, and put against the 
certainty of complete and hopeless blindness if the operation be 
not performed. 

Unless the Operation of Posterior Sclerotomy be employed 
with success, all eyes which take on the malignant course just 
mentioned are inevitably lost, are apt to become very painful, and 
must often be excised. A broad needle, or a Graefe's knife, is 
entered through the sclerotic, 8 or lo mm. behind the outer mar- 
gin of the cornea, and the blade is given a quarter turn on its 
axis, so as to make the wound to gape, or the latter may even be 
somewhat enlarged in a meridional direction. At the same time 
gentle pressure is applied, by means of the upper lid, on the center 
of the cornea. This causes fluid to escape through the scleral 
wound by the side of the knife, and it also causes the lens to go 
back into its place, with restoration of the anterior chamber. 
The pressure on the cornea may be maintained with advantage 
for a minute or somewhat longer. This proceeding has also 
been suggested as a cure for glaucoma, but has not yet been put 
into practice. It is probable that it would only temporarily re- 
duce the intra-ocular tension. 

As a rule the more acute the form of glaucoma, and the earlier 
in the disease the iridectomy be performed, the more favorable is 
the prognosis in respect of the result which may be expected. 
The saving of normal vision can only be looked for in those 



334 DISEASES OF THE EYE. 

cases where it has as yet fallen but little, or not at all, below the 
normal, and where the contraction of the field has barely com- 
menced. When the disease has interfered seriously with vision 
(of course I do not refer here to the enormous loss of sight im- 
mediately attendant upon an attack of acute glaucoma, for this 
is usually restored) we may not expect more than the retention 
of the status in quo. But even in this respect our prognosis 
should be most guarded, especially in chronic simple glaucoma, 
when the disease has advanced so far that the contraction of the 
field is found to have approached close to the fixation-point, al- 
though central vision may still be fairly good. Because in such 
cases, while the iridectomy may prove successful in so far as re- 
duction of tension is concerned, yet the contraction of the field — 
i e., the progress of the atrophy of the optic nerve — is often not 
arrested, and shortly afterwards may be found to engulf the cen- 
ter of vision. Indeed, where the contraction is near the fixation- 
point at one side, and is advanced in other directions, it is better 
not to operate. In general, while the result obtained from 
iridectomy in acute and subacute glaucoma, on the bases above 
laid down, can be regarded as amongst the most satisfactory in 
the whole range of ophthalmology, in chronic simple glaucoma 
iridectomy does not act with the same degree of certainty. 
Nevertheless, iridectomy, as holding out the only prospect of 
retention of any vision, should be recommended to the patient — 
except in every advanced cases — and that at as early a period in 
the disease as possible, before the field has become much con- 
tracted. When, as is often the case, the patient comes with one 
eye far advanced in the disease, and the other in an early stage of 
it, it is a question which eye should be first operated on. Prob- 
ably most surgeons operate on the worst eye first, with the re- 
sult that the measure having been applied too late, the result is 
unsatisfactory, and the patient declines to allow the better eye 
to be operated on. Hence some operators, with whom I agree, 
advise operation on the better eye first. 

In cases of acute or subacute glaucoma it has frequently been 
observed that shortly, even within a few hours, after the per- 
formance of the iridectomy, the other eye, previously healthy, or, 
at most, afifected with but slight premonitory symptoms, is at- 
tacked with glaucoma. It is probable that this is due to dilata- 
tion of the pupil, with crowding of the iris into the angle of the 
anterior chamber, in consequence of confinement in the dark 



GLAUCOMA. 335 

room, and eserin should be put into the sound eye as a precau- 
tion. 

It may here again (znde p. 257) be stated that the use of 
atropin, or of any other mydriatic, in an eye with a tendency to 
giaucoma is hable to bring on an acute attack of the disease, and 
must be carefully avoided in such cases. 

If the tension be not relieved by the iridectomy, a supple- 
mental iridectomy may be performed after a time, and von 
Graefe recommended that it should be placed at the opposite side 
of the pupil from the first coloboma. Dr. Gruening,^* of New 
York, performed five iridectomies in one eye for glaucoma. 
At the end the patient had no iris, but enjoyed a vision of 6-6. 

The Mode of Action of the Operation is not clearly known. 
Von Graefe at one time believed it to act by diminution of the 
secreting surface of the intra-ocular fluids. De Wecker ^^ and 
Stellwag ^^ — even previously to the formulation by Knies and 
Weber of the retention theory of glaucoma already referred 
to — held that the cure depended, not on the removal of the 
portion of iris, but on the incision in the corneo-sclerotic margin, 
or, rather, on the nature of the cicatrix resulting from that in- 
cision. They maintained that this cicatrix was formed of tissue, 
which admitted of a certain amount of filtration through it of the 
intra-ocular fluids, and that in this way the intra-ocular tension 
was kept down to the normal standard. This theory subse- 
quently gained support from that of Knies and Weber. 

Priestley Smith has satisfied himself that in a large number of 
successful iridectomies the success is due to a permanent corneo- 
scleral fistula — not merely a filtration cicatrix — having been 
formed. The same view is held by Treacher Collins,^' who finds 
that this permanent gap is maintained by a prolapse of a fold 
of iris into the wound. The latter author, indeed, entirely and 
definitely discards the filtration-cicatrix theory, for which he con- 
siders there is no evidence. In those cases where a fistula, as 
described, is not formed by the operation, Treacher Collins con- 
siders that the obstruction becomes freed, either by the iris being 
torn away at its thinnest part, — that is, its extreme root, — thus 
leaving a large portion of the filtration angle open for drainage ; 
or by the escape of the aqueous and the drag on the iris, inci- 
dental to the iridectomy, being sufiicient to dislodge the periphery 
of an iris which has only recently come into apposition with 
the cornea. 



33^ DISEASES OF THE EYE. 

De Wecker, Stellwag/^ and Quaglino ^^ sought to produce the 
corneo-scleral filtration cicatrix without the removal of a portion 
of iris. The peripheral position of the wound, however, ren- 
dered the proceeding difficult or impossible, owing to the tend- 
ency to prolapse of the iris which necessarily existed. The in- 
troduction of eserin into ophthalmic practice at last enabled de 
Wecker to place the operation on a surer footing, as the myosis 
produced by instillation of a solution of this drug into the eye 
insured the operator, to a great extent, against the danger of 
prolapse of the iris ; and hence. 

Sclerotomy, as the operation is called, came to be cultivated as 
a method for the relief of glaucoma. It has hitherto been em- 
ployed mainly in chronic simple glaucoma — a form in which, as 
I have stated, iridectomy is less satisfactory than in acute or 
subacute glaucoma. Care must be taken that the pupil is con- 
tracted to pinhole size, or nearly so, when the operation is about 



I 




Fig. 107. 

to be performed, as otherwise the danger of prolapse of the iris 
is very great. In those cases where eserin will not produce a 
sufficient myosis, sclerotomy should not be performed. 

The instrument used for performing the operation is von 
Graefe's cataract knife. A speculum having been applied, and 
the eyeball fixed, the point of the knife is entered into the an- 
terior chamber, through the corneo-sclerotic margin, at a point 
of its circumference corresponding to that selected for the 
puncture in cataract extraction, but i mm. removed from the 
corneal margin, as represented at a in Fig. 107. The counter- 
puncture is made at a point {h) corresponding to this, at the 
other side of the anterior chamber. With a slow sawing motion 
of the knife the section is enlarged upwards, until only a bridge 
of tissue, about 3 mm. broad, remains at c, and this is left un- 
divided, the better to guard against prolapse of the iris. The 
knife is now slowly withdrawn from the eye, care having been 
first taken that the aqueous humor is thoroughly evacuated, which 



GLAUCOMA. 337 

can be effected by tilting the edge of the knife sHghtly forwards, 
so as to make the Hps of the wound gape somewhat. If the pupil 
be quite round at the conclusion of the operation, the bandage 
may be applied, a drop of solution of eserin having been first 
instilled; but if the pupil be oval, or of other irregular shape, a 
tendency to prolapse of the iris is indicated, and the hard rubber 
or silver spatula should be introduced into the anterior chamber, 
to restore the pupil to its normal shape by gentle pushing of the 
iris. If there be an actual prolapse of the iris, an attempt may be 
made to repose it with the spatula; but should this not prove 
satisfactory the prolapse is to be abscised with scissors, thus 
turning the sclerotomy into an iridectomy. 

The operation has not gained many adherents, but Mr. Cross, 
of Bristol,^*^ regards it as of great value in the earlier stages of 
chronic glaucoma, before the sight is much reduced. The scle- 
rotomy he performs is that first proposed by Snellen. The pupil, 
having been contracted with eserin, a broad keratome is passed 
— as though an iridectomy were about to be made — from a punc- 
ture about 2 mm. outside the corneal margin into the anterior 
chamber. A wide wound is made, and the knife is carefully 
withdrawn to avoid prolapse of iris. Mr. Cross recommends 
this sclerotomy, too, when high tension recurs after having been 
temporarily relieved by an earlier iridectomy. The operation 
may be repeated again and again without danger, should the case 
demand it. 

Priestley Smith and Treacher Collins explain the cure by scle- 
rotomy as they do that by iridectomy. 

Sympathectomy. — Excision of the superior cervical ganglion 
of the sympathetic nerve is a new method for the treatment of 
glaucoma, which I shall merely mention ; for, although of in- 
terest, it is not sufficiently established to bring it within the scope 
of this work. Those who desire information concerning the 
method will find it by aid of the references -^ given at the end 
of this chapter. Sympathectomy is not recommended as a cure in 
itself, but rather as a supplement to iridectomy in cases of 
chronic glaucoma. It is said to act by contraction of the pupil, 
and reduction of the intra-ocular blood pressure. 

The Treahnent of Glaucoma by Myotics."^ — Eserin and pilo- 
carpin as eye-drops in i per cent, solutions often have the power 

* The action of the Myotics which are most in use will be found in 
Table II., p. 318. 



338 DISEASES OF THE EYE. 

of reducing glaucomatous tension. This power depends on the 
contraction of the pupil, and consequent drawing away of the 
base of the iris from the angle of the anterior chamber; and, if 
the myopic does not contract the pupil greatly, it will not reduce 
the tension. Cases of acute glaucoma, brought on by the in- 
judicious use of atropin, may frequently be completely and per- 
manently relieved by a myotic instilled a few times. In acute 
glaucoma of the ordinary type, the use of a myotic in the pre- 
monitory stage will often postpone the true glaucomatous at- 
tack, and even sometimes relieve the latter for the time; but the 
myotic treatment cannot produce a radical cure, and it should 
only be used to preserve the health of the eye, until the operation 
is performed. In chronic simple glaucoma, also, myotics bring 
down the tension if they contract the pupil, and may be used 
in those cases where the patient positively declines an operation, 
or where an operation in the fellow eye has not resulted satisfac- 
torily, or where an operation is contra-indicated by a very con- 
tracted field. The anti-glaucomatous action of the myotic only 
lasts so long as the pupil is contracted, and it must consequently 
be applied once or twice in the twenty-four hours. 

In the myotic treatment of glaucoma, Priestley Smith recom- 
mends the combination of cocain with the myotic in such propor- 
tions (say, about 1-4 per cent, of cocain to i per cent, of the my- 
otic) that the myotic will have the mastery over the pupil. For 
although, like every dilator of the pupil when used alone, cocain 
may promote high tension, yet it has the powers, invaluable in 
glaucoma, of contracting the ciliary blood-vessels, and of dimin- 
ishing the sensibility of the ciliary nerves ; and, when used in 
the foregoing manner, the advantage of each drug may be ob- 
tained, without any of the disadvantages of either. 

It may here be once more stated that, while myotics possess 
the power of reducing glaucomatous tension, atropin, and all 
mydriatics, bring on glaucoma, where there is already a tend- 
ency to it. In all old people, therefore, before atropin is used, 
it is well to ascertain that the tension is not too high. 

Treatment of Painful Blind Glaucomatous Eyes. — Eyes blind 
of acute glaucoma may, as I have stated, continue to be painful ; 
and may in this way render the patient's life very miserable. Iri- 
dectomy is very commonly performed to relieve the pain, al- 
though all hope of restoration of sight is lost ; but the operation 
sometimes fails in its object. Neurectomy (p. 280) seems to 



GLAUCOMA. 339 

offer a more certain result, and of course excision, or eviscera- 
tion, would have the same effect. Mules' operation should not be 
performed here. 

Secondary Glaucoma. 

In addition to the different forms of primary glaucoma above 
described, we find, as already stated, that high tension occurs 
as a sequel of diseased conditions previously existing in the 
eye. There are several diseased states which are liable to become 
complicated with glaucomatous tension; but it should be clearly 
understood that, in almost every instance, the immediate cause of 
the high tension is the same as in primary glaucoma — namely, a 
closure of the angle of the anterior chamber. 

The following are the chief conditions which are liable to lead 
to secondary glaucoma : 

a. Complete Posterior, or Ring Synechia (znde p. 252). The 
iris, being pushed forwards by the aqueous humor pent up be- 
hind it in the posterior part of the aqueous chamber, is pressed 
tightly against the cornea, and obliterates the angle of the an- 
terior chamber and the ways of exit. An iridectomy relieves 
the high tension here. 

b. Perforating Wounds or Ulcers of the Cornea, followed by 
incarceration of the iris in the resulting cicatrix. The iris, being 
drawn tautly towards the cornea, a large portion, or the whole, of 
the filtration angle may be closed by it. An iridectomy is indi- 
cated. Lang divides anterior synechise by means of his twin 
knives. 

c. Dislocation of the Crystalline Lens into the Anterior Cham- 
ber. Here the normal flow of the intra-ocular fluids through the 
pupil, on its way to the filtration angle, is arrested by reason 
of the presence of the lens in the anterior chamber. The on- 
ward current then presses the iris against the posterior surface 
of the lens, and the root of the iris, which is unsupported by the 
lens, against the periphery of the cornea, and in this way the 
angle of the anterior chamber is closed. In these cases the lens 
must be removed from the eye. 

d. Lateral (traumatic) Displacement of the Crystalline Lens. 
The lens, being pushed in between the ciliary processes and the 
vitreous humor, drives the root of the iris forwards against the 
cornea at that place, while in other parts of the circumference 



340 DISEASES OF THE EYE. 

the displaced vitreous acts in the same way. In these cases, too, 
the lens must be removed. 

e. Injury of the Crystalline Lens (vide chap. xiii.). The 
swelling- lens pushes the iris forwards against the angle of the 
anterior chamber. Evacuation of the lens should be performed. 

/. After Cataract Extraction. For explanation of this see 
chap. xiii. 

g. Intra-ocular Tumors (vide p. 293). The growth of the 
tumor gives rise to a transudation of serum from the chorioid 
which detaches the retina, and after a time pushes the lens, 
the ciliary processes, and the iris forwards, and thus closes the 
filtration angle. 

h. Serous-Cyclitis, or Iritis. Here the filtration angle is not 
closed. Priestley Smith thinks that the increased tension is due to 
diminished filtration-power of the eye, and perhaps by tissue 
changes around the filtration angle, and by deposit of exudation 
in the angle of the anterior chamber. 

Another, and very peculiar, form of secondary glaucoma is 

Hemorrhagic Glaucoma. — Retinal hemorrhages of the ordinary 
type are sometimes followed, a few weeks later, by increased in- 
tra-ocular tension, which generally assumes the symptoms of acute 
or subacute glaucoma, and, more rarely, those of chronic simple 
glaucoma. A satisfactory explanation for these cases has not, so 
far as I am aware, been offered. When such a glaucoma has 
become pronounced, it is not usually possible to distinguish it 
from a primary form of the disease. 

Treatment. — The disease is practically hopeless. Iridectomy 
is more likely to do harm than good, the operation being almost 
invariably followed by fresh intra-ocular hemorrhages, and by 
a further increase of tension. Sclerotomy is said by some to act 
with fairly good results in hemorrhagic glaucoma. The myotic 
treatment is powerless. 



Congenital Hydrophthalmos. 

Also known as Buphthalmos, and as Cornea Globosa. It is a 
glaucomatous disease of early childhood, of which the incipient 
stages are believed to be intra-uterine. The cornea becomes 
enormously enlarged in diameter, the anterior chamber deep, the 
iris trembling, and the sclerotic thinned. Increase of tension, 



GLAUCOMA. 341 

often attended by severe pain and cupping of the optic papilla, 
are usually present. 

The Pathology of the disease is obscure. Treacher Collins -^ 
holds that it is a failure in the separation of the iris from the 
back of the cornea at its extreme periphery, in course of the de- 
velopment of the eye, whereby the angle of the anterior chamber 
is blocked ; while E. von Hippel -^ believes it to be the result of an 
intra-uterine inflammation. 

Treatment. — Iridectomy and sclerotomy are alike followed by 
disastrous results in this disease. The myotic treatment is the 
only one applicable, and in a few cases it arrests the disease. 



References. 

^ " Von Graefe's Archiv,'" xxii. pt. 3. p. 163, and xxiii. pt. 2. p. 62. 

^ Ibid., xxiii. pt. i. p. i. 

^ '' Von Graefe's Archiv,'' xix. pt. 2. pp. 87-185. 

* " Ophth. Hosp. Rep.." x. p. 282. 

^ Ihid., ix. p. 199. and x. pp. 14, 89, 93. 

^ " Archiv. f. Augenheilkunde." xxxviii. p. 193. 

'"Ophth. Hosp. Rep..'' x. ; ''Trans. Internat.Med. Congress," 1881 ; 
" Ophthalmic Review," vol. vi. p. 191 ; " Pathology and Treatment of 
Glaucoma." London, 1891. 

^ " Trans. Ophth. Soc. U. K.." iii. p. 79. 

^ " Archiv f. Ophthal.," xv. pt. 3. p. 108. 

^° Ihid., ix. pt. 2. p. 205. 

^"^ Ihid., xiv. pt. 3, XV. pt. i, and xvi. pt. i. 

^ " Von Graefe's Archiv," xxvi. pt. 2. 

^^ " Archiv f. Ophthal.." iii. pt. 2. p. 456. 

" " Trans. American Ophthalmological Society," 1901. p. 314. 

" " Bericht der Ophthal. Gesellsch."' Heidelberg, 1869. 

^® " Der Intraoculare Druck," etc. Vienna, 1868. 

""Roy. Lond. Ophthal. Hosp. Rep.," December, 1891. and "Researches 
into the Anatomy and Patholog>' of the Eye." p. in. London, 1896. 

^* " Bericht der Ophthal. Gesellsch." Heidelberg. 1871. " Chirurgie Ocu- 
laire," p. 212. 

" " Annali di Ophthalmologia," i. pt. 2. p. 200. 

"° " Brit. Med. Jour.," August, 1900. 

^^Abadie, "Arch. d'Ophthal.," xix. p. 94; Axenfeld. " Sammlimg swang- 
loser Abhandungen a. d. Gebeiete der xAugenheilkunde." iv. i. p. i.; Ball. 
" Internat. Ophthal. Congress." Utrecht. 1899; Demicherie. '"Ann. d'Ocu- 
listique." cxxi. p. 188; Work Dodd, "Brit. Med. Jour.", August. 1900; 
Grunert, " Bericht der Ophthalmologischen Gesellschaft." Heidelberg, 
1900, p. 15; Jonnesco. "Internat. Med. Congress," Paris, 1900. 

^" " Researches into the Anatomy and Pathology of the Eye," p. 104. 
London. 1896. 

'^ " Bericht d Ophthal. Gesellsch." Heidelberg, p. 225, 1897. 



CHAPTER XIII. 

DISEASES OF THE CRYSTALLINE LENS. 

Cataract, by which is meant an opacity of the lens, may be 
said to be the only disease of this part of the eye. Cataract 
may be complete — i. e., occupying, in its final stage, the whole, 
or nearly the whole, of the lens ; or partial — i. e., occupying only 
part of the lens, and with little or no tendency to extend to other 
parts of it. 

Complete Cataracts. 

Of these, the most common is Senile Cataract. It occurs in 
persons of over fifty years of age, rarely in those under forty-five 
years of age. 

Progress, Pathogenesis, and Etiology of Senile Cataract. — In 
commencing or incipient senile cataract the opacity is found 
in the cortical layers of the lens, especially at its equator, and 
in the latter position can often only be detected with transmitted 
light from the ophthalmoscope mirror, or with focal illumina- 
tion, even when the pupil is dilated with atropin. This opacity 
takes the form of lines, or of triangular sectors, of which the 
bases are towards the equator of the lens, while the apices are 
towards its center. These lines and sectors look black with 
transmitted light, but gray with focal illumination, and between 
them clear lens-substance is present. Or, incipient cataract may 
first appear as a diffuse opacity in the layers surrounding the 
nucleus of the lens. Or, the opacity may commence both near 
the equator and around the nucleus at about the same time. Or, 
again, the opacity may in the beginning be disseminated through 
the cortex, in the form of flocculi, dots, and lines. In some 
cataracts, in a very incipient stage, there are no absolute opacities ; 
but with weak transmitted light — i. e., from a plane mirror — 
numbers of fine dark lines will be seen in the lens, which vanish 
and reappear according as the incidence of the light is altered ; 
while a little later true opacities make their appearance. Gradu- 

342 



THE CRYSTALLINE LENS. 343 

ally the cataract extends to other parts of the lens, until the 
whole cortical portion is opaque. 

In senile cataract the very nucleus itself does not become 
cataractous, although it is usually sclerosed (harder and 
drier). Sclerosis of the nucleus of the lens is a physiological con- 
dition of advanced life, and will be found in many an eye 
where there is no cataract. It gives to the senile non-cataractous 
lens, as seen with a dilated pupil or with focal illumination, a 
peculiar smoky appearance, which is often mistaken by inexperi- 
ence persons for cataract; but examination with transmitted 
light will show that there is no opacity. When a senile cataract 
has become complete, the sclerosed nucleus imparts to its center 
a brownish or yellowish hue, while the other parts of the lens 
are of a grayish-white. As a rule the most peripheral layers 
of the cortex are the last to become opaque. Accordingly as the 
lens becomes opaque, it often swells somewhat, and the anterior 
chamber consequently becomes a little shallower. 

Until the whole cortex is opaque a clear interval will be pres- 
ent between the iris and the cataractous part, and on examination 
with the oblique light a shadow of the iris will be thrown on the 
cataractous part at the side from which the light comes ; and the 
cataract, in this way, is proved to be immature in the strict sense. 
If the whole cortical substance be opaque, the thickness of the 
capsule alone will intervene between the pupillary margin and the 
opacity. In addition to this examination with the focal light the 
pupil should be dilated, and the lens examined by transmitted 
light from the ophthalmoscope mirror, when a completely opaque 
cataract should permit of no red reflection being obtained in any 
direction from the fundus oculi. 

As soon as the whole of the cortical substance has become 
opaque, the swelling of the lens begins to subside, and the an- 
terior chamber finally regains its normal depth. If there be no 
glittering sectors in the cortex, the cataract is now " mature," 
or " ripe " for operation — /. e., if an extraction operation be now 
undertaken, it is possible to deliver the lens in its entirety ; 
whereas, prior to this stage, some cortical substance would have 
been Hable to adhere to the capsule, and be left behind. 

But a cataract is immature, despite the absence of shadow from 
the iris, of the illuminable pupil, and even though the anterior 
chamber be of normal depth, if the cortex present well-marked, 
glittering sectors. The glitter of the different sectors varies 



344 DISEASES OF THE EYE. 

with the angle of iUumination, so that the surface appears faceted. 
In such a lens there are thin transparent flakes, as well as 
opaque flakes, close beneath the capsule; and, if extraction be 
undertaken, the former are very apt to remain within the eye in 
spite of every effort to remove them. A few months later the 
sectors lose their sharp contour, break down, and finally dis- 
appear. We can then depend upon the exit of the whole cat- 
aract. 

Yet in persons over sixty years of age, in whom the nucleus is 
usually large, many a cataract can be completely removed which 
does not come up to the strict standard of maturity just laid down ; 
and, at that time of life, I would not hesitate to operate, without 
waiting for absolute maturity, if the patient were materially in- 
commoded for want of sight. 

The foregoing is the most common course of events in the 
progress of a senile cataract; but there is a rather rare form 
of it, in which total opacity of the cortical layers never does 
come about. In this form the lens is occupied by radiating 
linear opacities up to the very capsule ; but between these opaque 
lines there are clear intervals, which may even admit of the 
fundus oculi being examined, although dimly, and which allow 
of a certain amount of sight. These cataracts can be successfully 
removed. 

After the stage of maturity a cataract gradually goes on to 
be hypermature. Here one of two changes takes place: either 
the cortical substance breaks down, and becomes fluid, the 
nucleus retaining its consistency, and gravitating to the lowest 
part of the capsule (Morgagnian cataract) ; or, more commonly, 
the cortical substance dries up, as it were, and finally comes to 
form, with the nucleus, a hard flat disc. Accompanying these 
changes in the lens substance are changes in the epithelium lining 
the inner surface of the anterior capsule, which result in a 
thickening of the capsule. In a Morgagnian cataract the fluid 
cortex finally undergoes absorption, and the anterior and pos- 
terior capsules come in contact (cataracta membranacea). In 
some cases the capsule remains more or less transparent, and the 
sight may greatly improve. Some cases are on record of spon- 
taneous cure of cataract, due to intracapsular absorption. 

The investigations of Priestley Smith ^ have shown that a 
diminished rate of growth of the lens precedes the formation 
of cataract; and it is held that the cataractous process in the 



THE CRYSTALLINE LENS. 345 

senile lens is the result, in the first instance, of a rapid sclerosis 
and shrinking of the nucleus. If the process of sclerosis and 
shrinking be very gradual, cataract does not appear, because the 
cortical layers of the lens have time to accommodate themselves 
to the altered state of things ; but if the shrinkage be rapid the 
cortical layers cannot so rapidly accommodate themselves, and 
then the fibrillse of these layers become separated somewhat from 
each other, and fluid collects in the interspaces. This fluid it is 
Vvhich causes the disintegration of the lens substance, gradually 
leading to opacity of the whole lens. As the opacity increases, 
more fluid is present in the lens, and it is this which causes 
the swelling of the lens already referred to. When the whole 
cortex has become opaque the fluid contents begin to diminish, 
and the lens returns to its normal size. Senile cataract, then, is 
entirely a local process, and is not dependent on any disordered 
state of the general health. 

The dimensions of the nucleus vary a good deal. In some 
cataracts it is very small, and these are called soft cataracts, as 
they consist chiefly of the soft cortical substance. In others — 
and as a rule in patients over sixty years of age — the nucleus is 
large, and these are called hard cataracts, although they are not 
hard throughout. The size of the nucleus can be estniiated pretty 
accurately by the extent and intensity of the yellowish or brown- 
ish reflection, which is obtainable by focal illumination from 
the center of the cataract. 

In some senile cataracts the sclerosis is not confined to the 
nucleus, but extends to the cortical layers as well. This causes 
much disturbance of sight, and the term cataracta nigra is given 
to these lenses, from their very dark hue, although they are not 
cataracts in the true sense of the term. They require operation, 
and, as they are always of large size, wide openings have to be 
made to deliver them. 

In the lenses of young people there is no nucleus ; conse- 
quently, in the complete cataracts of children and of young 
adults, there is no nucleus ; the whole lens becomes opaque, and 
the cataract is always soft. Although the starting-point of cat- 
aract in children and young adults cannot be a shrinking of the 
nucleus, as there is none, yet the opacity is no doubt due to the 
taking up of fluid by the lens. 

The natives of India are very prone to cataract, and at an 

early time of life, as are also persons in cold countries whose 
29 



346 DISEASES OF THE EYE. 

business exposes their eyes for hours at a time to the heat and 
glare of furnaces — e. g., glass-blowers, smiths, cooks, etc. 

The Symptoms to which senile cataract gives rise consist, in 
the earliest stages, in the appearance of motes before the eyes 
and of monocular polyopia. Motes are complained of also in 
disease of the vitreous humor; but in those cases they float over 
a large portion of the field of vision, while in commencing cat- 
aract they occupy always the same relative position in the field. 
The polyopia is the result of irregular refraction in the media, 
which causes many images of the objects looked at to be formed 
on the retina. This symptom seems to annoy the patients more 
especially in the evening, when they look at gas or candle flames, 
the moon, etc. It is often complained of before there is any 
actual opacity in the lens, at a time when only the clefts filled with 
fluid between the fibrillse can first be detected with weak trans- 
mitted light from the ophthalmoscope, as dark lines vanishing 
and reappearing according as the incidence of the light is al- 
tered. 

In some cases of incipient cataract there is an increase in the 
refracting power of the lens, with the result that the patient be- 
comes slightly myopic, if, previously, he have been emmetropic. 

Gradually, as the opacity of the lens extends to other parts 
of it, the acuteness of vision becomes affected ; and this is the 
more marked the more the cortex at the anterior and posterior 
poles of the lens is involved. In those cases where the equa- 
torial parts of the lens are but little affected, while the polar 
regions are a good deal affected, the patients see better 
in the dusk, or with their backs to the light, than when 
their eyes are exposed to a strong light. The reason for this is 
that in the dusk the pupil is dilated, and light can pass through 
the clearer periphery of the lens, while in a strong light the 
pupil is contracted. On the other hand, when the opacity is con- 
fined rather to the equator of the lens, a strong light is not dis- 
turbing to sight ; or, if the center of the lens be quite clear, a 
strong light may even be pleasant to the patient. 

But, according as the lens becomes more and more opaque, the 
acuteness of vision is reduced, until, finally, even large objects 
cannot be discerned, and only quantitative perception of light is 
left. Some cataracts, however, when quite rip^ still admit of 
finger-counting at a few feet. 

In advanced stages of the disease, as the opacities occupy a 



THE CRYSTALLINE LENS. 347 

great portion of, or the entire cortex, they are easily recognized 
even by ordinary dayHght, often giving a grayish appearance to 
the pupil. Inflammatory exudation in the area of the pupil would 
afford a somewhat similar appearance, but would be attended by 
other signs of the previous inflammatory process, such as 
synechiae, disorganization of the iris, etc., and it would be seen to 
lie more in the plane of the iris than does any lental opacity. 

The length of time occupied by the ripening of a cataract varies 
in different cases from a few months to many years. In the 
very old the progress is, in general, more rapid than at an earlier 
time of life. That form which commences at the equator as 
fine lines is slower than that with flocculent opacities, or than 
that in which the cortex around the nucleus is likewise implicated 
at an early period. 

All examinations as to the condition of the lens are rendered 
easier and more conclusive if the pupil be previously dilated with 
atropin ; but the tension of the eye should be ascertained before 
atropin is instilled, lest glaucoma, or a tendency to it, be present. 

Treatment. — No external local applications, nor internal 
medicines, are of any avail in the treatment of cataract at any 
stage. Removal of the cataract from the eye by operation is 
the only cure for blindness caused by it. 

In cases of incipient cataract, or in those, rather, which have 
advanced somewhat beyond this stage, we often find that vision 
is improved, or made more pleasant, by the wearing of tinted 
glasses to moderate the light. With commencing cataract, where 
slight myopia has come on, low concave glasses for distant vision 
will be found of service ; while, for reading, stenopeic glasses 
sometimes give good results. Yet, as a rule, patients are un- 
willing to use any of these aids. 

Dilatation of the pupil with atropin is in many cases of the 
greatest benefit, especially where the nucleus is much more 
opaque than the cortical portion; but sometimes the diffusion of 
light resulting is most distressing to the patient, and greater im- 
pairment and confusion of vision are produced, and for this rea- 
son care in the prescription of atropin is demanded. 

Patients with incipient or advancing cataract may, with im- 
munity, be allowed to make every use they can of the sight they 
possess ; and the surgeon should give them hints as to the ar- 
rangement of light in their rooms, and for their work, etc., so as 
to enable them to employ their sight to the best advantage. 



348. DISEASES OF THE EYE. 

The truly distressing period in the progress of cataract, when 
both eyes are affected, Hes between the advent of that degree of 
bhndness which incapacitates the patient for reading or writing, 
or for making his way about alone, and the occurrence of 
maturity, or of that degree of maturity which is deemed requisite 
for successful removal. This is often a lengthened time ; it may 
be months or years. Fortunately, in many instances one cataract 
is much more advanced than that in the other eye ; and then no 
such trial need be gone through. 

Artificial Ripening. — In order to hasten the maturity of a 
cataract, puncture of its anterior capsule has been proposed and 
practiced with success, but has not been generally adopted, from 
the fear that it might set up iritis, or produce increased tension 
from excessive swelling of the cataract. Forster ^ effected ar- 
tificial ripening by performing an iridectomy, which can after- 
wards be utilized for the extraction. This in itself often ex- 
pedites the ripening, probably by disturbing the arrangement of 
the lens-fibers when the aqueous humor flows off, and the dis- 
turbance can be promoted by gently rubbing or stroking the lens 
through the cornea, immediately after the iridectomy, with the 
angle of a strabismus hook. This same massage of the crystal- 
line lens may be employed with good result after simple tapping 
of the aqueous humor without iridectomy. Soon after this, a 
rapid increase in the opacity is often noticed, so that in from 
four to eight weeks extraction can be undertaken. The diffi- 
culty of this rubbing or massage of the lens lies in the estima- 
tion of the pressure to be applied ; for if it be excessive the zonula 
may easily be ruptured, with the result of loss of vitreous when 
the extraction comes to be performed. The best results are ob- 
tained in cases of cataract where there is a firm and somewhat 
opaque nucleus, and where a certain amount of opacity already 
exists in the anterior cortical substance. I have occasionally em- 
ployed the method, with satisfactory results; but some operators 
have seen iritis follow the proceeding. 

The question whether the cataract in one eye should be ex- 
tracted until both eyes are blind is often asked by patients. The 
answer is : A patient with one mature cataract, and the other 
progressing towards maturity, should have the ripe cataract re- 
moved. Hypermaturity is thus avoided, and also the stage of 
blindness above referred to. Again, if there be a ripe cataract 
in one eye, and not even incipient cataract in the other, it is often 



THE CRYSTALLINE LENS. 349 

advisable to operate for the purpose of increasing the binocular 
field of vision. 

Complete Cataract of Young People. — The spontaneous oc- 
currence of total cataract in the youthful lens is of rare occurrence, 
and its pathogenesis is still unknown. 

Treatmenr. — Discission. 

Diabetic Cataract. — This is a complete opacity of the crystal- 
line lens occurring in diabetes, and due to disturbed nutrition. It 
has been proved by experiment that cataract can be produced by 
injecting solutions of sugar into the blood ; but analysis of the 
aqueous humor in diabetic patients shows that the amount of sugar 
contained in it is not sufficient to account for the cataract. The 
cataract does not differ in appearance or consistency from other 
cataracts, according to the time of life of the patient. 

Treatment and Prognosis. — Contrary to a very general opinion, 
these cases are not very unfavorable for extraction operations. 
I have operated on several cases of this kind, and always with 
success, save once, when the eye was lost by intra-ocular hemor- 
rhage; and I have also seen such cases operated on successfully 
by others. There is no other method of restoring sight to these 
patients, who often live a long time. Ophthalmic surgeons of 
distinction inform me that occasionally patients operated on for 
diabetic cataract die of coma within about a fortnight or so after 
the operation ; and they seemed to think that this was not dia- 
betic coma of the ordinary kind, but coma caused in some way 
by the nervous system being upset by the operation. I have 
not had this untoward experience. 

The operation of discission in these cases is apt to be followed 
by severe iritis. 

Complete Congenital Cataract. — Children are sometimes born 
with crystalline lenses opaque in all their layers, while the other 
tissues of the eye are healthy. With congenital cataract defects 
of the chorioid or retina, or congenital amblyopia without oph- 
thalmoscopic appearances, are also sometimes present, and these 
are usually indicated by nystagmus. 

Treatnien t. — Discission. 

Black Cataract. — This name, as above stated, is sometimes 
given to cases of extreme sclerosis of the lens, in which it assumes 
a dark brown color; but in other cases the lens is really black, 
the pigment being derived from the blood (hemin, or hematin). 
An instance has recently been observed in which the lens was 



350 DISEASES OF THE EYE. 

jet-black from this cause. The prognosis in these cases is not 
good, as they are often complicated with disease of the chorioid, 
or with hemorrhages in the vitreous humor. 

Partial Cataracts. 

These are nearly all congenital. 

Central Lental Cataract. — This is a congenital and usually 
non-progressive form. It is an opacity of the central, or oldest, 
lens-fibers, while the peripheral layers remain clear. 

Treatment. — Discission or iridectomy. 

Zonular, or Lamellar, Cataract. — This is congenital, or forms 
in early infancy, and is the most common kind of cataract in chil- 
dren. It usually is present in both eyes, but it has been seen in 
one eye only. In it the very center of the lens is clear (Fig. io8), 
while around this is a cataractous layer or zone, and outside that 
again the peripheral layers are transparent. Most of these cases 



Fig. io8. 

are non-progressive, but occasionally the whole lens does become 
opaque, and usually then there have been previously some slight 
opacities in the otherwise clear cortical layers. 

With oblique illumination the cortical layers of the lens are 
seen to be clear, while towards the center of the lens a uniform 
gray circular opacity will be observed. The diameter of this 
opacity may be small, perhaps not more than 3 mm. or 4 mm., 
or it may extend very nearly to the equator of the lens. If the 
pupil be dilated, and the lens examined with transmitted light, 
the cataractous portion will be seen as a more or less dark disc 
in the center of the lens, while all round it is seen the red light 
reflected from the fundus oculi. The center of this disc is either 
of the same degree of darkness as its margin or but very little 
darker ; and this point serves to distinguish this form of cataract 
from one in which the whole center of the lens is opaque. In the 
latter case it is evident that the center of the opacity must be 
darker than its margin. In many cases small radial opacities 



THE CRYSTALLINE LEXS. 351 

are seen round the equator of the lens, passing from the anterior 
to the posterior surface, their concavity embracing the circum- 
ference of the central opacity. 

It is probable that lamellar cataract is due to some transient 
disturbance of nutrition in utero, occurring at the time the af- 
fected layers of the lens are being laid down. But against 
this view is the fact that one-half of the lens only may present 
the appearance of zonular cataract. The subjects of it are 
usually rickety, as shown by the irregular and imperfect develop- 
ment of the teeth, and by rachitic alterations in the bones of the 
skull. Convulsions during infancy in these patients are common. 

The Treatment of central lental cataract and of zonular cat- 
aract is similar, and consists in either discission or iridectomy. 
The latter is very decidedly to be preferred in those cases in 
which the central opacity is so small that, on dilatation of the 
pupil, the acuteness of vision, with the aid of a stenopeic slit, 
is increased in a satisfactory degree. When the improvement is 
but slight, the breaking up of the lens with a needle is indicated. 
The advantage of iridectomy over discission, when the former 
can be adopted, is that no spectacles are afterwards required, and 
that the power of accommodation is retained. 

Congenital cataracts may be needled any time after dentition 
is completed. 

Anterior Polar, or Pyramidal, Cataract may be either con- 
genital or acquired. In the former case it must be referred to 
some inflammatory disturbance occurring about the third period 
of development of the lens. In both cases the mode of origin 
of the opacity is the same, whether it be punctiform, flake-like, or 
pyramidal — namely, by contact of the lens with an inflamed cornea. 
In fetal life this may occur without any perforation of the cornea, 
as there is then no anterior chamber. /\fter birth a perforating 
ulcer of the cornea is a necessary precursor of it, but the ulcer 
need not be central (p. 104). This contact with an inflamed and 
ulcerating cornea may lead to subcapsular cell-proliferation at 
that portion of the capsule which is exposed in the pupillary area, 
and consequent subcapsular opacity in this small area. 

No Treatment is required, as vision is not affected. 

Fusiform, or Spindle-Shaped, Cataract is also congenital, 
and is rare. . It consists in an axial opacity extending from pole 
to pole, and may be combined with central or lamellar opacity. 
The foregoing forms of cataract, with the exception, perhaps, 



352 DISEASES OF THE EYE. 

of the anterior polar and genuine black cataract, are primary; 
that is to say, they are not dependent on, or the result of, dis- 
ease in other parts of the eye. 

Secondary Cataract. 

Some diseased states of the eye give rise to secondary cata- 
ract. 

Of this a partial kind is 

Posterior Polar Cataract. — This form is seen, with transmitted 
light, as a star-shaped or rose-shaped opacity in the most pos- 
terior layers of the posterior cortical substance, its center cor- 
responding with the posterior pole of the eye. 

Posterior polar cataract is usually found in eyes which are 
the subjects of disseminated chorioiditis, retinitis pigmentosa, or 
diseased vitreous humor. It sometimes progresses, and be- 
comes a complete cataract ; and then the prognosis for sight after 
extraction is not very good, owing to the disease which is pres- 
ent in the deep parts of the eye. 

The additional disturbance of sight caused by the presence 
of posterior polar cataract depends a good deal upon its density. 

Total Secondary Cataract often ensues upon contact of the 
lens with inflammatory products in the eye — e. g., where false 
membranes have been produced by inflammation in the uveal tract. 
It is sometimes then called Cataracta Acer eta, when the iris or 
ciliary processes are adherent to it. Cataract is also caused by 
detachment of the retina, intra-ocular tumor, absolute glaucoma, 
dislocation of the lens, etc. The reason of this is that the lens, in 
these cases, imbibes abnormal nutrient fluid from the diseased 
tissues with which it is in contact. 

Such cataracts often undergo a further degeneration, and be- 
some calcareous. Calcareous cataracts are easily recognized by 
their densely white or yellowish-white appearance; and almost 
always indicate deep-seated disease in the eye, even when the 
functions, so far as they can be tested, are fairly good. 

These secondary cataracts rarely come within the range of 
Treatment, as the diseases which give rise to them are usually 
destructive of sight. When, occasionally, they can be dealt with 
they should be extracted. 

The term secondary cataract is also used in cases in which, 
after a cataract extraction, the capsule of the crystalline lens, 



THE CRYSTALLINE LENS. 353 

which is left behind, presents an obstacle to good sight. This 
will be referred to again further on, and is not to be classed 
with the conditions dealt with in this paragraph. 

Capsular Cataract. 

By this term is meant an opacity of the anterior capsule or of 
the capsular epithelium. It is usually confined to the center or 
anterior pole, and is most frequently seen in overripe senile cata- 
racts and in secondary cataracts. 

Traumatic Cataract. 

Every injury which opens the capsule of the lens is liable to 
cause cataract, by reason of the admission of some of the sur- 
rounding fluids to the lenticular substance. 

Perforating injuries with sharp instruments, or the entrance 
of small foreign bodies — in both cases, as a rule, through the 
cornea — are the most common injuries that produce traumatic 
cataract. But blows upon the eye, without any perforating 
wound, also, although rarely, produce cataract. In these latter 
cases there is a rupture of the capsule, either at the equator of the 
lens, or on its posterior or anterior surface. 

Within a few hours after a perforating injury of the anterior 
capsule, the lens substance in the immediate neighborhood of 
the opening becomes opaque, swells, and protrudes as a gray 
fluffy-looking mass, through the opening in the capsule into the 
anterior chamber, where it gradually breaks up, dissolves, and 
becomes absorbed. It is immediately followed by other portions 
of the lens which have become cataractous, until, after a time, 
the whole lens will have disappeared, and the pupil again be- 
come black. Marcus Gunn suggests •'' that the explanation of 
the solution of the cataract in the anterior chamber consists in the 
fact that globulin is normally soluble in a weak solution of 
chlorid of sodium, such as we have in the fluid of the anterior 
chamber. The absorption of a traumatic cataract takes many 
weeks ; and ultimately the eye sees well if a suitable convex 
lens be put before it. 

But the course of events just sketched is the most favorable 
one, and is hardly likely to take place in a case which is wholly 
untreated. In the first place the swelling of the lens — especially 
if it be rapid, in consequence of a wide opening in the capsule — 

30 



354 DISEASES OF THE EYE. 

is liable to irritate the iris, and to cause iritis ; or to push the 
periphery of the iris forwards against the periphery of the 
cornea, block the angle of the anterior chamber, and cause sec- 
ondary glaucoma. 

Moreover, violent plastic or purulent uveitis may come on, as 
the consequence of the introduction of infective matter on the 
perforating object, or foreign body, which causes the cataract. 
Where this occurs the case enters into the category of diseases of 
the uveal tract; and the cataract, as such, becomes a minor con- 
sideration. 

Again, we sometimes meet with traumatic cataracts which 
do not undergo any absorption process, but simply remain sta- 
tionary; or, in the course of years, undergo secondary changes 
similar to those which occur in senile cataract. In these in- 
stances the trauma is usually a blow on the eye, not a perforating 
injury ; and it is believed that the rupture of the capsule closes 
soon after the blow, and hence no lens matter can escape into the 
anterior chamber ; also, the rupture in many of these cases is 
probably at the equator of the lens, where the aqueous would not 
readily get access to the lenticular substance. 

Where the cataract is produced by a small foreign body flying 
through the cornea and into the lens, it is a matter of importance, 
for the prognosis, to decide whether the foreign body be in the 
lens or have passed through it into the deeper parts of the eye. 
In the former case we may hope to extract it with the cataractous 
lens; while in the latter case we must fear that it will set up 
dangerous inflammatory reaction. In such cases the lens should 
be well searched with focal illumination, and the transmitted 
light may also be of use ; but it must be remembered that in these 
traumatic cataracts there are often glittering sectors in their deep 
parts, which may readily be mistaken for a metallic foreign body. 
If the foreign body be of steel or iron, the sideroscope may be 
employed for its detection, or the Rontgen rays may be utilized. 

Treatment. — The pupil should be kept dilated with atropin, 
in order to draw the iris out of the way of the swelling lens 
matter ; and nothing more is necessary if complications do not 
arise. But should iritis or high tension come on — and the sur- 
geon must constantly test the tension — it is important, without 
further delay, to extract as much as possible of the cataract. 
This may be done either without an iridectomy, through a 
linear incision some lo mm. long in the upper third of the cornea, 



THE CRYSTALLINE LENS. 355 

or with an iridectomy, through an incision in the upper margin 
of the cornea. 

If a foreign body be present in the lens, extraction of the 
latter with the foreign body should invariably be undertaken. 

Where violent purulent or plastic uveitis is set up by the 
trauma, the treatment resolves itself into that for these inflam- 
mations. 

Operations for Cataract, 

With regard to the State of Health of the Patient about to 
be operated on it is desirable, as in every operation, that it should 
be good. Still, we have so often in these cases to deal with very 
old people, that we cannot in every instance require sound organs 
and a robust constitution ; and, as a matter of experience, I have 
not found serious disease of the heart, lungs, and liver, even when 
they all existed in the same individual, any impediment to a suc- 
cessful operation. Diabetes is no absolute contra-indication, and 
even in the presence of Bright's disease I have operated success- 
fully. Very advanced years form no obstacle. I have frequently 
operated for cataract on persons over eighty years of age, and 
always with success. 

The State of the Eye itself should be carefully investigated 
prior to proposing or undertaking an operation for cataract, and 
is a much more important matter than the general health. Above 
all things, it is to be determined whether there be intra-ocular 
complications, which would neutralize the result of a successful 
operation, such as detachment of the retina, disseminated 
chorioiditis, atrophy of the optic nerve, etc. The examination of 
the eye before the lens has become opaque, if the surgeon have 
had that opportunity, will be the most reliable basis upon which 
to go ; and for this reason a careful note should be taken of the 
condition of the fundus in each case of incipient cataract. The 
examination of the fundus of the other eye, if its lens be clear, 
may help in determining the point in so far as those intra-ocular 
diseases are concerned which are apt to be binocular. Again, the 
condition of the anterior capsule of the lens should be observed, 
for a defined glistening white square patch, about 2 mm. broad, 
situated in the center of the capsule, tells the tale of intra-ocular 
mischief. It cannot be confounded with the more diffused stri- 
ated and punctated capsular alterations due to overripeness. 

Finally, the functions of the eye should be examined. With 



356 DISEASES OF THE EYE. 

an uncomplicated cataract of the most opaque kind good percep- 
tion of light should be present, so that the light, say, of a candle 
some two meters distant may be distinguished. In less dense 
cataracts fingers may be counted at i m. or 1.5 m. when full 
maturity has been attained. The field of vision must be ex- 
amined by means of the " projection of light " — i. e., a lighted 
candle held in different parts of the field should be recognized 
by the patient, who is required to point his finger in the direction 
of the light, as it is moved rapidly from one part of the field to 
another. This examination can also be made by means of the 
light reflected from the ophthalmoscope mirror. If the patient 
fail to project the light in any direction, a diseased condition in 
the corresponding part of the retina may be suspected. Yet in 
cases of very old uncomplicated cataract the patients often project 
the light in some one direction, no matter where it may come 
from. A certain degree of intelligence on the part of the pa- 
tient is required for this test. 

By the foregoing means most intra-ocular complications of a 
serious nature can be detected ; but there is at least one against 
which I know of no safeguard, namely, a small circumscribed 
spot of chorioido-retinal degeneration at the macula lutea (central 
senile chorioiditis). After removal of a cataract from an eye 
affected in this way, the patient's vision is so much improved as 
to enable him to go about alone, but reading will still remain an 
impossibility for him. 

The Cornea should he Examined. — Such corneal opacities as 
would seriously compromise vision may contra-indicate the opera- 
tion ; but slighter opacities, discernible only with oblique illumina- 
tion, would merely diminish the future acuteness of vision, and 
would require a corresponding prognosis to be given before 
operation. 

The Condition of the Appendages of the Eye, too, must be 
examined. Should there be any conjunctivitis, blepharitis, or 
dacryocystitis, it ought to be cured or alleviated before the opera- 
tion is undertaken. Very successful operations, it is true, may 
be performed in the presence of chronic dacryocystitis, or of 
granular ophthalmia; but the risk is great, and it is in all re- 
spects wiser to reduce their activity to a minimum. Some sur- 
geons, in cases of dacryocystitis, temporarily obliterate the lacri- 
mal puncta by introducing a red-hot needle. A better means is 
extirpation of the lacrimal sac. 



THE CRYSTALLINE LENS. 



357 



EXTR.-^CTION OF CaTARACT. 

Linear Extraction. — The extraction through a Hnear incision 
in the cornea is apphcable only to soft, or fluid, cataracts, in 
persons under the age of twenty-five. The instruments required 
are: A spring hd elevator (Fig. 109), a fixation forceps, a wide 




Fig. 109. 

keratome (Fig. no) or a Graefe's cataract knife, a cystotome 
(Fig. in), and a Critchett's vectis (Fig. 112). 

The soeculum having been applied, a fold of conjunctiva close 
to the margin of the cornea, and at the inner end of the horizontal 





Fig. 1 10. 



Fig. III. 



Fig. 112. 



meridian of the latter, is seized (Fig. 113) with the fixation for- 
ceps, and the eye fixed bv it throughout the operation. The point 
of the keratome is now entered into the cornea in its horizontal 
meridian, about 4 mm. from its outer margin, and is passed into 



358 



DISEASES OF THE EYE. 



the anterior chamber; or, the incision may be made in the upper 
part of the cornea. The blade of the knife is then laid in a 
plane parallel to that of the iris, and pushed on until the corneal 
incision has attained a length of 6 or 7 mm. The point of the 
knife being now laid close to the posterior surface of the 
cornea — in order that no injury may be done to the iris or lens 




Fig. 113. 

when the aqueous humor commences to flow off — the instrument 
is very slowly withdrawn, so that the aqueous humor may come 
away gradually, without causing prolapse of the iris. In with- 
drawing the knife it is well to enlarge the inner aspect of one or 
other end of the wound, by a suitable motion of the instrument 
in that direction. 

The keratome being now laid aside, the cystotome is passed 




into the anterior chamber (Fig. 114) as far as the opposite pupil- 
lary margin, care being taken, by keeping the sharp point of the 
instrument directed either up or down, not to entangle it in the 
wound or in the iris. The point is now turned directly on the 
anterior capsule, and, by withdrawing the cystotome towards the 
corneal incision, an opening in the capsule of the width of the 



THE CRYSTALLINE LENS. 



359 



pupil is produced. The cystotome is then removed from the 
anterior chamber, with the same precautions as on its entrance. 



I 



Fig. 115. 



Fig.- 116. 



Fig. 117. 



Fig. 118 



The edge of the vectis is then placed on the outer lip of 
the corneal incision, and the latter is made to gape somewhat, 



360 DISEASES OF THE EYE. 

gentle pressure being at the same time applied to the inner aspect 
of the eye by the fixation forceps, and in this way the lens is 
evacuated. When the pupil has become quite black the operation 
is concluded. If pressure does not at first clear the pupil com- 
pletely, the speculum should be removed, the eyelids closed, a 
compress applied, and a few minutes allowed to elapse, in order 
that some aqueous humor may be secreted. A renewal of the 
efforts to clear the pupil will probably now be successful, or, if 
not, another pause may be made, and then fresh attempts em- 
ployed until the pupil is quite clear. It is unwise to insert the 
vectis into the eye to withdraw the fragments ; and if some of 
these should be left behind, no ill results need necessarily fol- 
low, although iritis is more apt to supervene than if the lens be 
thoroughly evacuated. Fragments left behind become absorbed. 
If there be a prolapse of the iris which cannot be reposed it must 
be abscised. 

Von Graefe, Waldau, and Critchett endeavored, by increasing 
the size of the incision, placing it in the corneo-sclerotic margin, 
performing an iridectomy, and introducing a vectis for delivery 
of the cataract, to make the linear extraction applicable to senile 
cataracts. The successes derived from these modifications were 
not, however, more satisfactory than those obtained from the 
old Flap Operation. But these experiments led von Graefe to the 
operation, a modification of which is now very generally em- 
ployed. He called his operation 

The Modified Peripheral Linear Extraction. — The instru- 
ments required are : A wire lid-speculum, a fixation forceps with 
spring catch, a von Graefe's cataract knife (Fig. 115), a curved 
iris forceps, an iris scissors or a de Wecker's forceps-scissors (Fig. 
116), a bent cystotome, a hard rubber spoon (Fig. 117), and a 
hard rubber, tortoiseshell, or silver spatula (Fig. 118). 

Before proceeding to operate, the eye is thoroughly cocainized 
by the instillation of about three drops of a 2 per cent, solution 
of hydrochlorate of cocain, at intervals of two or three minutes. 

Antiseptic Measures, similar to those used for the Three Mil- 
limeter Flap Operation (vide infra), are to be carefully attended 
to. 

The Operation. — The speculum having been applied, the eye 
is steadied by seizing a fold of conjunctiva with its subcon- 
junctival tissue, close to the lower margin of the cornea, and in a 
prolongation of the vertical meridian of the latter. The eye is 



THE CRYSTALLINE LENS. 361 

now drawn gently downwards, the patient assisting in the mo- 
tion. The point of the Graefe's knife, its cutting edge being 
directed upwards, is then entered into the corneo-sclerotic mar- 
gin at a point [A in Fig. 119) about 1.5 m. from the outer and 
upper corneal margin, and 2 mm. below the level of the tangent 
which would pass through the highest point of the corneal mar- 
gin. The blade is held in a plane parallel to that of the iris, and 
is pushed on into the anterior chamber until its point reaches 
the point C, some 7 or 8 mm. of the blade being now in the an- 
terior chamber. The handle of the knife is then lowered, so 
that the point of the blade is brought up to B, where it is made 
to pass out through the corneo-sclerotic margin, this counter- 
puncture corresponding in position, with reference to the corneal 
margin, to the point of entrance A. The edge of the knife is now 
turned slightly forwards, and by one or two sawing motions the 
incision A B is completed in the corneo-sclerotic margin. The 
blade still lies under the conjunctiva, wliich is divided, the edge 




Fig. 119. 

of the instrument being turned more forwards, or even somewhat 
downwards, as it is not desirable to have too large a conjunctival 
flap. 

The advantage of this incision lies in its peripheral position, 
which is almost in the plane of the crystalline lens, and, conse- 
quently enables the cataract to be delivered without revolution on 
its axis. At a later period von Graefe altered the incision, so that, 
puncture and counterpuncture lying as described, the center of 
the incision passed through the apex of the clear cornea instead 
of through the corneo-sclerotic margin. This, by making the 
incision more nearly a segment of a greater circle of a sphere, 
made it as linear as possible, and consequently, in his opinion, 
its margins adapted themselves more readily. 

The next step in the operation is an iridectomy, a portion of 
iris corresponding to the whole length of the wound, or nearly as 
much, being excised. This iridectomy is necessary, or advisable, 
chiefly because of the peripheral position of the wound, which 



362 DISEASES OF THE EYE. 

would render prolapse of the iris very liable to occur ; but it also 
facilitates the delivery of the lens and cortical masses. The 
subsequent stages — capsulotomy and delivery of the lens — are 
similar in their details to those in the Three Millimeter Flap 
Operation, to be presently described. 

It was found that the advantages of the position and form of 
the incision in this procedure were largely counterbalanced by 
the danger of prolapse of the vitreous, the difficulty of proper 
reposition of the angles of the coloboma, and the liability to 
cyclitis, all entailed by the peripheral incision, and consequently 
this incision has been abandoned by nearly all operators. 

Out of this method grew that one which is known as the 

Three Millimeter Flap Operation, or, more commonly. The 
Combined Operation (/. e., combined with an iridectomy), first 
proposed by de Wecker. I shall describe the operation as I am 
in the habit of performing it ; and I may here say that for success 
in the cataract operation it is necessary, not only to select the 
method which seems the most rational, but also to devote the ut- 
most attention to a series of minute details in its performance. 

Preparation of the Patient. — A gentle purgative is given the 
day before the operation, so that the bowels need not be disturbed 
for two days after the operation. The face is washed with hot 
water and soap shortly before the operation. 

Preparation of the Eye. — Half an hour before the operation a 
drop of a sterilized 2 per cent, solution of sulphate of eserin is 
dropped into the eye, and this is repeated a quarter of an hour 
later. Just before the operation, at intervals of two minutes, 
three drops of a sterilized 2 per cent, solution of hydrochlorate 
of cocain are dropped into the eye. Finally, the lids having been 
everted, the conjunctival sac is washed out with sterilized physio- 
logical solution of common salt, particular attention being paid 
to the fornix of each lid, and to the inner and outer canthus. 
Then the skin of the eyelids and immediate surroundings of the 
eye are freely washed with the same solution. 

Preparation of the Instruments. — The instruments required 
are the same as those for the Modified Linear Extraction. Im- 
mediately before the operation they are sterilized by boiling ; they 
are then plunged for a moment into absolute alcohol, and laid on 
a sterilized porcelain tray, under a sterilized cloth, until required 
for use. 

During the Progress of the Operation small bits of lint, wet 



THE CRYSTALLINE LENS. 363 

with the sterilized salt solution, are employed to wipe away 
coagula, cortical masses, etc., and are not employed a second 
time. An assistant should place the instruments in the surgeon's 
hand in their turn, and take out of his hand those he has used, 
in such a manner as to render it unnecessary for him to look 
away, even for a moment, from the field of operation. 

TJie Operation. — A spring wire lid-speculum is applied. The 
eye is fixed with a catch fixation-forceps by a fold of conjunctiva 
and subconjunctival tissue, below the vertical meridian of the 
cornea, or a little to one side of this line (Fig. 120). 

The point of the knife is entered just in the margin of the clear 
cornea, at the outer extremity of a horizontal line which would 
pass 3 mm. below the summit of the cornea. This line is easily 
found by placing the knife, which is about 2 mm. broad, hori- 
zontally across the cornea, so that a margin of clear corneal tissue 
I m. broad may remain exposed between the knife and the sum- 
mit of the cornea. The knife is then passed cautiously through 
the anterior chamber, and the counterpuncture is made in the 
corneal margin at the inner extremity of the horizontal line de- 
scribed, and the incision is then finished in the corneal margin 
by a few slow to-and-fro motions of the knife. 

Owing to the action of the eserin, the iris does not prolapse. 
The incision, between puncture and counterpuncture, lies in the 
clear cornea at its very margin, as represented by the dotted line 
in Fig. 120. This incision is no longer linear, but slightly 
curved. It is found, however, to adapt itself readily, and, being 
less peripheral than the true von Graefe incision, the objections 
to the latter are obviated. 

The Second Stage of the Operation consists in an Iridectomy. 
The fixation of the eye having been given over to the assistant, 
the iridectomy is performed by passing a curved iris forceps into 
the anterior chamber, seizing the smallest possible portion of the 
sphincter of the iris at a point corresponding to the center of the 
incision, drawing it out, and with the forceps-scissors excising a 
very small central bit of iris. This is done either by making 
two snips in the iris, one at either side of and close to the forceps, 
each of them reaching to the periphery of the iris, and then a 
third cut which joins these two at the base ; or, the forceps- 
scissors 'being approached from over the cornea — /. e., at right 
angles to the wound — the coloboma may be formed with one snip 
of the instrument, and, if care be taken to keep the blades close to 



364 DISEASES OF THE EYE. 

the forceps, a narrow, neat coloboma may thus be obtained. It 
is unnecessary to excise a large portion of iris, although in von 
Graefe's original operation a portion corresponding to the entire 
length of the wound used to be taken away. A small coloboma, 
say of 2 mm. to 3 mm. in width, as in Fig. 100, is sufficient to 
allow of an easy delivery of the lens by doing away with the re- 
sistance of the sphincter iridis, and to prevent secondary pro- 
lapse of the iris (vide infra) ; and its advantages over a wide 
iridectomy, from an esthetic point of view, are obvious. It is 
always, therefore, my object to obtain the smallest possible 
coloboma. The procuring of a neat coloboma is much facilitated 
if, prior to the operation, the pupil has been contracted (see Fig. 




Fig. 120. 

120) by the instillation of one or two drops of solution of sul- 
phate of eserin, as above recommended. 

The Third Stage of the Operation is the Capsulotomy. The 
operator takes the fixation forceps from his assistant, who then 
raises the speculum and eyelids slightly off the globe, in order 
that no pressure may be exerted on the latter during the remain- 
der of the operation. The surgeon, passing the cystotome into 
the anterior chamber, divides the anterior capsule of the lens by 
two incisions, each from the lower pupillary margin upwards, one 
directed outwards, the other inwards, as far as the anterior sur- 
face of the lens can be seen, while finally a third incision is made 
along the upper periphery of the lens. An extensive opening in 
the capsule is of great importance, as otherwise difficulty ni de- 
livery of the lens may be experienced, and because a small open- 
ing renders the occurrence of secondary cataract more likely. In 



THE CRYSTALLINE LENS. 365 

dividing the capsule it is important not to dig into the lens, as 
this, in the case of a hard cataract, is apt to dislocate it. A 
rather oblique application of the cystotome to the capsule is, for 
this reason, the best. 

The cystotome often drags a tag of the capsule into the corneal 
wound, where it lies until the end of the operation, and where, 
owing to its transparency, it may easily pass unnoticed. Such a 
tag acts as a foreign body, and may subsequently form the start- 
ing-point of troublesome complications. 

Capsule forceps have been invented for the purpose of taking 
away a large portion of the anterior capsule ; but this does not 
altogether obviate the danger of capsule in the wound, nor does 
it do away with the likelihood of secondary cataract. I have no 
objection to the method, but it does not seem to have any advan- 
tages over that just described in cases where the capsule is not 
thickened. But when the anterior capsule is thickened it is always 
desirable to tear away a central portion of it with forceps. 

Gayet of Lyons ^ and Knapp of New York ^ have proposed a 
method of opening the capsule termed peripheral division — i. e., 
they make only one opening in the capsule at the upper periphery 
of the lens with a very sharp needle cystotome, which is passed 
along the whole length of the corneal section, a wide iridectomy 
having been made for this purpose. The chief advantages 
claimed for this method are : Safety from a tag of capsule in the 
wound, and safety from iritis caused by irritation from particles 
of lenticular substance left behind after delivery of the lens. On 
the other hand, it has the disadvantages of the secondary opera- 
tion on the capsule, which becomes necessary in a much larger 
proportion of the cases than where a free central opening is made. 

The Fourth Stage is the Delivery of the Cataract. The eye 
is drawn gently downwards — the patient being called on to assist 
in this motion by looking towards his feet ; the convex edge of 
the hard rubber spoon is placed just below the lower edge of the 
cornea, and gentle pressure is exercised on this place, the pressure 
to be gradually increased until the upper margin of the lens pre- 
sents itself in the wound, when, the same pressure being main- 
tained, the spoon is advanced over the cornea in an upward direc- 
tion, pushing the lens before it and out through the wound. As 
soon as the greatest diameter of the lens has passed the wound 
the pressure of the spoon should immediately be diminished, lest 
rupture of the zonula be caused. The fixation-forceps and 



3^6 DISEASES OF THE EYE. 

speculum are now removed from the eye, and a cold sterilized 
compress is laid on the closed lids. 

It may be noted that the fixation-forceps and the speculum are 
used until this late stage in the operation is reached. Probably 
most operators do likewise. Some, however, use neither fixation- 
forceps nor speculum from beginning to end of the operation; 
while others discard the fixation-forceps when the corneal section 
is completed, but retain the speculum until after the iridectomy 
only, delivering the lens with the finger placed on the lower lid. 
I think that the use of the fixation-forceps and the speculum until 
after the lens is delivered gives more security and stability to the 
operator than the other methods, and I see in it no counter-dis- 
advantages. 

The Fifth Stage consists in Freeing the Pupil of any Cortical 
Masses which may have been rubbed ofif in the passage of the 
lens through the wound, and in what is called the Toilet of the 
Wound. 

The presence of cortical remains is recognized by the pupil not 
having become quite black, or by the vision not being such as it 
ought to be (fingers counted at several feet), or by inspection of 
the cataract just removed showing that some portions of it are 
left behind. The use also of focal electric illumination for the 
detection of cortical fragments is very advantageous. If any 
fragments be present, the cold sterilized compress having lain on 
the eye for a few minutes to enable some aqueous humor to col- 
lect, the operator, facing the patient, raises the upper lid with the 
thumb of left hand, while, with the first and second fingers of the 
right hand laid on the lower lid, light rotatory motions are made 
with this lid over the cornea so as to collect the masses towards 
the pupil, and then a few rapid light motions upwards, with the 
margin of the lid, drive these masses towards, and out of, the 
wound. 

Care and delicacy of touch are required in order to perfonn 
this lid-maneuver successfully, without rupturing the hyaloid by 
undue pressure. 

With an iris-forceps the blood-clots which may adhere to the 
wound are now removed. 

I then employ the following means, to prevent the possibility 
of any portion of capsule being incarcerated in the wound dur- 
ing healing : A bent iris-forceps is passed open between the lips 
of the wound, closed, and drawn gently out again. Frequently 



THE CRYSTALLINE LENS. 36; 

a tag of capsule will have been captured by the forceps, and is 
snipped off with the scissors, or it may be that no capsule is 
caught. The forceps is then similarly inserted at an adjacent 
part of the wound ; and in this manner the wound is searched 
from end to end for capsule. In about 25 per cent, of the cases 
a tag of capsule is found present. I regard this measure as an 
important one, for I believe that it effectually removes the one 
serious drawback to the valuable operation under consider- 
ation. 

Finally, the coloboma has to be seen to. The peripheral por- 
tions of the iris corresponding to the ends of the wound are apt 
to have become prolapsed in the course of the operation, and to 
have displaced the angles of the coloboma upwards. If this be 
not corrected the prolapsed portions of the iris heal in the wound, 
and cause bulgings there later on, the pupil in the course of some 
months becoming drawn up towards the cicatrix. Hence, in 
every case, even where everything seems to be in order, it is im- 
portant to pass the narrow spatula into the anterior chamber, 
and to gently stroke down each pillar of the coloboma as far as 
it can be brought. The instillation of eserin before the com- 
mencement of the operation will cause the sphincter iridis to 
assist in producing the desired result. All this is aptly termed 
the toilet of the wound. 

The sight of the eye should then be tested by finger-counting, 
as this affords the patient satisfaction, and lends him courage for 
the next few days of strict quiet. Finally, the conjunctival sac 
is flooded with the sterilized saline solution. 

The dressing is now applied. A piece of dry sterilized lint, 
sufficiently large to extend 1-4 inch beyond the orbital margin 
in every direction, is laid on the closed eyelids. Pieces of ster- 
ilized absorbent cotton-wool are laid on this, the hollows at the 
inner canthus, etc., being carefully filled up ; so that, when the 
bandage is put on, it may exert equal pressure on every part of 
the eye. I apply three turns of a narrow roller bandage over the 
dressing and round the head, in the manner which was customary 
in von Graefe's clinique ; but various other, and doubtless equally 
good, forms of bandage are in use. The pressure of the bandage 
need only be sufficient to maintain the dressing firmly in its place. 
It is usual to keep the other eye closed by a light bandage. 

I am opposed to the after-treatment of cataract operations 
without bandage, as advocated by some surgeons. It is by no 



368 DISEASES OF THE EYE. 

means a new method, and I do not doubt that many cases recover 
under it. I do not beheve, however, that in a long series of cases 
the same percentage of recoveries can be obtained by it as with 
the bandage. 

Accidents Liable to Occur during the Operation. — The Wound 
may be made Too Small, and the delivery of the lens, conse- 
quently, may be so difficult that the margins of the wound be- 
come contused, and consequently suppuration may be promoted. 
The zonula, too, may be ruptured by the excessive pressure, from 
efforts to force the lens out through the narrow aperture, and pro- 
lapse of the vitreous may ensue. If the directions above given 
be carefully attended to, the vast majority of both hard and soft 
cataracts may be extracted without difficulty ; but should the 
wound be made too small, it can best be enlarged by the forceps- 
scissors, or a blunt-pointed knife made for the purpose. Where 
the presence of an unusually large hard cataract is diagnosed, it 
is important to make the incision larger ab initio^ by placing 
puncture and counterpuncture nearer to the horizontal meridian 
of the cornea than above directed. 

Hemorrhage into the Anterior Chamber may take place. It 
may be from the iris, from the corneo-sclerotic margin, or from 
the conjunctiva. Pressure with the spatula on the cornea, which 
causes the wound to gape, is often successful in clearing the 
chamber of blood, which might interfere with accurate division 
of the capsule. Yet, when this cannot be completely got rid of, 
the capsulotomy can be performed by the exercise of greater 
care. Cocain, by its power to contract the blood-vessels, has ren- 
dered this hemorrhage a less common complication than it used 
to be. 

Prolapse of the Vitreous Humor. — This may be due to a too 
peripheral position of the wound, support being thus taken away 
from the zonula, and the danger of its occurrence was a disad- 
vantage of the completely corneo-sclerotic wound practiced at 
one time by von Graefe. The Three Millimeter Flap Operation 
is less liable to be attended with loss of vitreous. This accident 
may also be caused by undue pressure made on the eyeball by the 
speculum, fixation forceps, or spoon, or by the lower lid during 
the lid-maneuver. It may be due to defective zonula with fluid 
vitreous humor. When the vitreous prolapses prior to delivery 
of the lens, the latter falls back into the eye, and can only be de- 
livered by at once drawing it out with a Critchett's, Taylor's, or 



THE CRYSTALLINE LENS. 369 

other suitable vectis ; and this may be regarded as one of the most 
serious accidents which can occur in the course of the operation. 
Loss of vitreous after deHvery of the lens is less serious ; in- 
deed, a considerable portion of the vitreous may then be lost 
without ill result to the eye ; yet it increases the traumatism, and 
renders inflammatory reaction more liable to occur. Opacities in 
the posterior chamber of the eye are frequently an ultimate re- 
sult of loss of vitreous ; but a much more serious consequence is 
sometimes seen in detachment of the retina. 

Normal After-Progress. — Soon after the completion of a nor- 
mal operation, the effect of the cocain having passed off, some 
smarting commences, and continues for four or five hours. After 
that time the patient has no unpleasant sensation in the eye, un- 
less it be some itching, or a slight momentary pain or sensation of 
a foreign body, especially when the eye is moved under the 
bandage. The first dressing is made in forty-eight hours, in a 
manner similar to that immediately after the operation, a drop of 
atropin being instilled, as also at each successive dressing; and 
the sterilized salt solution is used for freely washing the margms 
of the eyelids, some of it being allowed to trickle into the con- 
junctival sac. At this first dressing it is well to abstain from a 
very minute or lengthened examiination of the eye ; but, if the lid 
be gently raised, the wound will be found closed, the cornea clear, 
the anterior chamber completely restored, and the pupil semi- 
dilated and black. The subsequent dressings are made night and 
morning, for the purpose of instilling atropin. On the third day 
after the operation the patient may be allowed to sit up, the room 
being kept moderately dark ; and on the fifth or sixth day the 
bandage may be left aside permanently, and dark glasses worn 
in its stead. In the course of a few days more the patient, hav- 
ing been gradually used to more light, may be allowed out of 
doors. It is desirable to continue the use of atropin for about a 
fortnight longer, or until all abnormal vascular injection of the 
white of the eye has disappeared, as until then there is danger of 
iritis. (For selection of glasses in aphakia see end of this 
chapter.) 

Irregularities in the Process of Healing. — The pain may con- 
tinue longer than four or five hours, and it is then well to quiet 
it by a hypodermic injection of morphia in the corresponding 
temple. Should severe pain come on some hours later it is apt 
to be due to an accumulation of tears under the eyelids, and it 

31 



370 DISEASES OF THE EYE. 

immediately subsides on the bandage being removed and exit 
given to the tears by sHghtly opening the eye. 

Late Appearance of the Anterior Chamber. — At the first 
dressing it will sometimes be found that there is no anterior 
chamber, although the appearance of the w^ound is quite satis- 
factory ; but this need occasion no alarm, as the anterior chamber 
is sometimes not restored for a week. Should a more length- 
ened absence of the anterior chamber be noticed, it may be due 
to the presence of a small tag of capsule in the wound, and it is 
then desirable to search the latter with a forceps, and to cut off 
any capsule which may be found there. 

Striped Keratitis. — At this dressing also it may sometimes be 
observed that there is a more or less well-marked striated cloudi- 
ness of the cornea, extending over nearly the whole of it, or occu- 
pying only a part in the immediate neighborhood of the wound. 

This opacity is, according to some, the result of injury to the 
endothelium of the posterior surface of the cornea during the 
operation by instruments, or by the chemical action of an anti- 
septic lotion, when such a lotion has been used. Leber has shown 
that the entrance of even the aqueous humor, through a loss of 
substance in the endothelium, is sufficient to cause the fibers of 
the true cornea to swell and become opaque, just as the crystal- 
line lens is acted on if its capsule be opened. The endothelium 
of the posterior surface of the cornea in fact it is which protects 
the latter from being infiltrated by the aqueous humor. 

The explanation given by Hess,^ however, seems a very rea- 
sonable one, namely, that it is due to folding of the posterior 
layers of the cornea, on account of the difiference in tension in the 
vertical and horizontal direction. His conclusions are based on 
microscopic examination and experiment. 

This so-called striped keratitis is, for the most part, of no 
serious import, as it usually passes away in a few days, and leaves 
the cornea perfectly clear; and folding of the posterior layers 
would account for these cases. But now and then cases do occur 
in which the process is very intense, and where a permanent 
white opacity remains in the cornea over the pupillary area, with 
consequent serious deterioration of vision. These severe cases 
are most apt to be caused by the introduction of an antiseptic 
solution into the anterior chamber ; for the chemical action of the 
antiseptic on the corneal tissues is more damaging, and therefore 
the opacity it produces more permanent, than is the action of the 



THE CRYSTALLINE LENS. 371 

aqueous humor. Sublimate lotion is the antiseptic which has 
been most often to blame, probably because it is the antiseptic in 
most general use. With the i in 5000 solution which I at one time 
employed I never had the severe form, and rarely the mild form ; 
but then I never deliberately introduced the solution into the an- 
terior chamber. I have had only one case of the severe form, 
and in it, by mistake, a sublimate lotion of i in 2500 was used for 
irrigation of the surface of the eye. At a later period I employed 
a solution of only i in 10,000, but this I have abandoned in favor 
of the sterilized physiological solution of salt, as I have stated. 

Suppuration of the Wound. — This is a danger which is very 
much rarer than it was prior to the introduction of aseptic sur- 
gery ; indeed, it is almost banished from the cataract operation. 
When it occurs it usually does so between the twelfth and thirty- 
sixth hour after the operation, rarely earlier or later, and is a 
very serious event; for in the vast majority of cases, do the sur- 
geon what he may, it leads to loss of the eye. Its onset is made 




Fig. 121. 

known by severe pain of a continuous aching kind in and about 
the eye; and is thus easily distinguished from the slight, short, 
stabbing pain, with long intermissions, which some patients com- 
plain of, and which has no evil import. On removing the band- 
age the eye will be found full of tears, and the wound covered 
with a layer of muco-pus, which can be removed with the forceps 
in one mass, while the aqueous humor and cornea may already 
present some opacity. In some hours more the corneal opacity 
increases considerably, the iris becomes distinctly inflamed, and 
the pupil filled with a mass of inflammatory exudation. The in- 
flammatory process may remain confined to the wound and iris, 
and when, in the course of some weeks, it entirely subsides, it 
leaves the pupil drawn up towards the wound, so that an appear- 
ance as in Fig. 121 is presented ; or, the inflammation may strike 
into the ciliary body and chorioid, and produce purulent panoph- 
thalmitis, with total destruction of the eye. 

To combat Suppuration the best method is the immediate 
cauterization of the corneal wound in its whole extent with the 



372 DISEASES OF THE EYE. 

galvano-cautery. Also, the wound may be opened up from end 
to end with a spatula, the aqueous humor evacuated, and the an- 
terior chamber washed out with injections of sublimate solution 
I in 10,000, while the conjunctival sac is irrigated with the same 
solution. If necessary, these measures are to be repeated at inter- 
vals of eight or ten hours. Subconjunctival or intra-ocular injec- 
tions of sublimate may also be tried. 

Iritis. — Apart from the iritis which occurs in connection with 
suppuration of the wound, this complication is most usually due 
to irritation from masses of cortical lens-substance left behind, 
or to infection during the operation, which can show itself in this 
way instead of by suppuration. Iritis does not usually come on 
for some days after the operation. It is ushered in with the usual 
symptoms of pain, and is generally of the plastic variety. Gen- 
eral plastic uveitis may be set up, and sympathetic ophthalmitis 
may result. Treatment consists in strict confinement to a dark 
room, atropin, warm fomentations, leeching, and, internally, 
salicylate of soda is most useful. In these cases vision is liable 
to be damaged by pupillary exudation, which remains as a per- 
manent obstruction to vision. 

Detachment of the Chorioid. — Fuchs ^ has pointed out that 
detachment of the chorioid occurs some days after cataract ex- 
traction, in some of the cases in which the anterior chamber does 
not form, or in which, having formed, it becomes empty again. 
The detachment occurs, too, occasionally after iridectomy uncon- 
nected with cataract extraction. It can be seen with the ophthal- 
moscope, and sometimes even with the focal illumination. Vision 
while the lesion is at its height is seriously affected, but the prog- 
nosis is good, for the detached portion always becomes re- 
posed. 

Cystoid Cicatrix. — After convalescence, all foregoing dan- 
gers having been escaped, the cicatrix in the corneal margin 
sometimes bulges and becomes semi-transparent, presenting the 
appearance of a vesicle, and may attain a large size. The ex- 
tremities of the late incision are the most common positions for 
this condition, but it may occupy the entire length of the cicatrix. 
It does not generally come on for some weeks, or more, after the 
operation. In some cases it is caused by a tag of iris which is 
incarcerated in the wound ; but in other cases by a small piece of 
capsule, which has similarly healed in the wound. Irrcgularitv 
in curvature of the cornea, and consequent irregular astigmatism^ 



THE CRYSTALLINE LENS. 373 

are the least of its evil consequences. If the condition be caused 
by incarceration of iris, the pupil will be gradually drawn close 
to the upper corneo-sclerotic margin; while, if it be caused by a 
portion of capsule, iridocyclitis may be produced. Whether the 
iris or the capsule be the cause, these eyes are always exposed to 
the danger of a sudden onset of purulent iridochorioiditis (see 
p. 263). All this demonstrates the immense importance of at- 
tention to those details of the operation which are calculated to 
obviate incarceration of iris, or of capsule, in the cicatrix. 

Cataract Extraction without Iridectomy, or more commonly, 
The Simple Operation. — This method is older than the Linear, 
von Graefe's, or the Three Millimeter Flap Operation, and used 
to be known as the Flap Operation. It has been revived within 
recent years by many distinguished operators. It differs from 
the Three Millimeter Flap Operation in that the incision occu- 
pies a greater extent (about one-third) of the circumference of 
the cornea, and that no iridectomy is made. Formerly the knife 
used was triangular in shape (Beer's knife), but von Graefe's 
cataract knife is the instrument now employed. The round 
pupil, and consequent somewhat prettier appearance of the eye, 
is the one advantage which can be claimed for this procedure 
over the Three Millimeter Flap Operation as above described ; 
for vision with a circular pupil is not better than where a small 
iridectomy has been made. As a set-ofT against the circular pupil, 
the extraction without iridectomy exposes the eye to the serious 
danger of prolapse of the iris into the wound. Those who 
operate after this method make it a rule to perform an iridectomy 
in all cases where they cannot satisfactorily repose the iris after 
delivery of the lens ; but, even where they can repose it well, they 
are not secure against the occurrence of a prolapse within the 
first two or three days after the operation ; nor do they find that 
eserin, or any other means, provides the desired safeguard. It 
is admitted that prolapse of the iris takes place after a number 
of these operations, and that there is no means of foretelling in 
what eyes it will occur. The prolapsed portion of iris heals in 
the wound, which then, in a few weeks, becomes more or less 
cystoid and bulging, causing displacement of the pupil and 
irregular curvature of the cornea, with resulting deterioration of 
vision. Nor is this all ; for such eyes are liable — weeks, months, 
or even years after the operation — to take on severe iridocyclitis, 
ending in total loss of sight. Another disadvantage of this 



374 DISEASES OF THE EYE. 

operation is, that removal of cortical remains cannot be so effectu- 
ally performed as where a coloboma has been made. 

Therefore, while admitting the charm of a circular pupil, I 
am of opinion that the question is not whether the appearance of 
some of the eyes operated on is pleasing to us and to others who 
inspect them, but rather what advantage the greatest number of 
persons operated on derive from the operation. With senti- 
mental talk about " mutilation " of the iris I do not sympathize. 

The explanation why, in the simple extraction, prolapse of the 
iris with subsequent incarceration is more liable to occur, even 
some days after the operation, than in the combined operation, 
and why it is so difficult to devise a sure means for preventing 
the accident, as, also, how it is that even a very narrow coloboma 
is, almost always, sufficient to protect the eye from this disaster, 
is the following: Within a few hours after the operation the 
wound in the corneal margin commonly closes, the aqueous hu- 
mor collects, and the anterior chamber is restored. But it takes 
many hours more for the delicate union of the lips of the wound 
to become quite consolidated, and during this time it requires 
but little — a cough, a sneeze, a motion of the head, the neces- 
sary efforts in the use of a urinal or bed-pan, no matter how care- 
ful the nursing — to rupture the newly formed union ; and, as a 
matter of fact, this often does take place. The aqueous humor 
then flows away through the wound with a sudden gush, and, 
where the simple extraction has been employed, carries with it 
the iris. In this event, it is that portion of the aqueous humor 
which is situated behind the iris which is chiefly concerned in the 
ins-prolapse; the aqueous humor in the anterior part of the an- 
terior chamber probably flows off without influencing the posi- 
tion of the iris. 

Many who perform the simple operation endeavor to prevent 
secondary iris-prolapse by a spastic contraction of the pupil, pro- 
duced by eserin, which is instilled at the conclusion of the opera- 
tion, and, again, by some a few hours afterwards. In most in- 
stances the desired end is by this means effected. But there is 
still a considerable percentage of the cases in which the contrac- 
tion of the sphincter iridis is overcome by the pressure of the 
aqueous humor from behind, and iris-prolapse takes place. 

The formation of even a narrow coloboma prevents prolapse 
of the iris when the wound bursts, but this is not because the por- 
tion of iris which is liable to prolapse has been taken away, for 



THE CRYSTALLINE LENS. 375 

that would be nothing less than the whole of that part of the iris 
which corresponds to the length of the opening in the corneal 
margin. The coloboma averts secondary iris-prolapse, because 
it provides a way, a sluice, for the aqueous humor contained in 
the posterior part of the anterior chamber to escape directly 
through the wound, without carrying with it the iris in its rush; 
and it is evident that the narrowest coloboma which can be 
formed will be amply sufficient for the purpose. To my mind a 
narrow iridectomy here is no '' mutilation of the iris," but rather 
a measure which rests upon a sound basis, and which is calculated 
to insure the safety of the eye in an important particular. 

As to disfigurement of the eye, there is practically none, when 
the coloboma is so narrow, and is situated in the upper part of the 
iris. The pupil, too, is movable, almost, if not quite, as much so, 
as in most cases of simple extraction. For a narrow coloboma 
does not render the pupil immovable. Where there are no ad- 
hesions between the pupillary margin and the capsule, as fre- 
quently happens, the reaction to light is active, a drop of atropin 
will dilate the pupil widely, and a drop of eserin will contract it. 

Mental Derangements after Cataract Extractions. — After cata- 
ract extractions, during the period of confinement to bed, passing 
mental disturbances are sometimes seen in old people. This usu- 
ally takes the form of confusion of ideas, hallucinations, and ter- 
ror. It is hard to assign a cause for it, but probably it is mainly 
due to the quiet, and to the exclusion of light following on a 
period of some anxiety and excitement. A few doses of sul- 
phonal, and permission to sit up — at least in bed — with the ad- 
mission of more daylight, will be the best measures to adopt in 
such a case ; and speedy restoration of mental equilibrium may 
be looked for with confidence. Care should be taken not to mis- 
take the symptoms of atropin poisoning for this form of mental 
disturbance. 

Secondary Glaucoma after Cataract Extraction occurs now and 
then, by whatever method the extraction may have been per- 
formed. This is contrary to what one would have expected, in 
view of the diminished contents of the globe, by reason of absence 
of the lens, and especially where an iridectomy has been made. 
High tension in these instances may come on soon after recovery 
from the cataract operation, or after a good result has existed for 
many years. Treacher Collins' ^ microscopic investigations show 
that in these cases either the iris, the capsule, or the hyaloid has 



376 DISEASES OF THE EYE. 

become entangled in the wound and incarcerated in the subse- 
quent cicatrix, and it seems that this leads in some cases to closure 
of the filtration angle in its entire circumference. Mr. Collins 
says : In all eyes in which glaucoma comes on after ex- 
traction of cataract there is adhesion to or entanglement 
of the lens capsule in the extraction scar. This adhesion 
or entanglement keeps the root of the iris, or the anterior 
I of the ciliary process if the iris has been removed up to 

ithe periphery, in close contact with the back of the cornea 
in the region of the coloboma, and so keeps the angle of 
the chamber blocked in that situation. The advanced 
position which the capsule takes, by reason of its attach- 
ment to the cornea, draws forwards the iris lying in front 
of it, and in this way approximates the root of the iris, 
elsewhere than in the region of the coloboma, to the peri- 
phery of the cornea. In some cases, especially in those in 
which the extraction scar is very corneal, the advance in 
the position of the capsule is so great that the apposition 
of the cornea and iris is actually occasioned. In such 
cases the increased tension follows as soon as the wound 
has closed after the operation. The adhesion of the lens 
capsule to the extraction scar is sometimes composed of 
inflammatory exudation ; this, on organizing and con- 
tracting, tends gradually to advance more and more the 
position of the capsule, and consequently that of the iris. 
Such a gradual advance would explain those cases in 
which the increased tension does not make its appearance 
until some time after the cataract has been removed. 

A wide iridectomy, or a sclerotomy, should be made as 
soon as possible after the high tension shows itself, and 
by this means many of these eyes may be saved. Simple 
division of the capsule has produced a good effect in some 
cases. 

Discission or Dilaceration means the tearing of the 
anterior capsule of the lens with a needle, so as to give the 
Fig. 122. aqueous humor access to the lenticular fibers, which causes 
them to swell, and gradually to become soft, and then to be 
absorbed. The larger the capsular opening the more freely is the 
aqueous brought in contact with the lens, and the more rapid is its 
swelling. The rapidity of the swelling and absorption depend, also, 
on the consistence of the lens. The softer it is the more rapid is 



THE CRYSTALLINE LENS. 377 

the process, the completion of which may require from a few 
weeks to many months. It is wise to make the first discission 
of moderate dimensions, in order to test the irritabihty of the eye, 
especially in adults. 

The instruments required are a spring speculum, a fixation- 
forceps, and a Bowman's stop-needle (Fig. 122). The pupil is 
to be dilated with atropin. 

The eye having been cocainized, the speculum applied, and 
the eye fixed close to the inner margin of the cornea, the needle 
is passed perpendicularly through the cornea in its lower and 
outer quadrant, at a point corresponding to the margin of the 
dilated pupil. It is then advanced upwards to the upper margin 
of the pupil (Fig. 123), where it is passed into the capsule, but 
not deeply into the lens, and a vertical incision is effected by 




Fig. 123. 



withdrawing the instrument slightly. If an extensive opening 
in the capsule be wished for, a horizontal incision can be added 
to the vertical one by a corresponding motion of the needle. Dur- 
ing these manuevers the cornea, at the point of puncture, must 
form the fulcrum for the motions of the instrument. The instru- 
ment is then withdrawn from the eye, and some aqueous hu- 
mor escapes through the opening. Atropin is instilled, and 
the bandage applied. The patient is kept in bed for a day, and 
then the bandage may be dispensed with, and dark spectacles 
worn. The iris is to be kept well under the influence of atropin, 
until the absorption of the lens is completed. Repetition of the 
operation is called for, if the opening be so small as to admit of 
but a very slow absorption of the lens, or if, as sometimes hap- 
pens, the opening should become closed up. 
32 



378 DISEASES OF THE EYE. 

This method is applicable to all complete cataracts up to the 
twenty-fifth year of age, and to those lamellar cataracts up to the 
same age in which the opacity approaches so close to the periphery 
of the lens that nothing can be gained by an iridectomy. After 
the above age, the increasing hardness of the nucleus, and the in- 
creasing irritability of the iris, render the method unsuitable. 

Discission is a safe procedure, when used with the above in- 
dications and precautions. The danger chiefly to be feared is 
iritis, from pressure on the iris of the swelling lens masses. 
When this occurs, or is threatened, removal of the cataract by 
a linear incision in the cornea should be at once performed. A 
safeguard against iritis may be had in a preliminary iridectomy 
(von Graefe), and it is perhaps well to do this in all cases over 
fifteen years of age, the discission following some weeks after- 
wards. 

Another danger consists in glaucomatous increase of tension 
(secondary glaucoma), which may come on without any sub- 
jective symptoms, although severe pain usually attends it, while 
the absorption of the lens runs its proper course. It may hap- 
pen, consequently, that, when absorption of the cataract is com- 
pleted, the eye will be found blind from glaucoma. Frequent 
testings of the tension of the eye during the cure are therefore 
a most important precaution. Should the tension rise, removal 
of the lens through a linear incision in the cornea is at once 
indicated, or the suction operation may be employed. 

Suction Operation of Cataract. — ^This method can only be 
used for semi-fluid or soft cataracts. 

The pupil having been well dilated with atropin, and the eye 
cocainized, a free opening is made in the capsule of the lens 
with a discission needle. A linear incision is then made in the 
cornea about halfway between its center and its margin, and 
the point of a Bowman's or a Teale's syringe introduced through 
it, and through the opening in the capsule, into the substance of 
the lens. Gentle suction is then applied, and the lens substance 
drawn into the syringe. The syringe should not be passed behind 
the iris. If it be thought that the cataract is not sufficiently soft, 
it is desirable to allow some time (a fortnight or so) to elapse 
between the discission and the suction, in order that the lens sub- 
stance may undergo disintegration by the action of the aqueous 
humor. The suction operation is now much less frequently used 
than formerly. . ■ ,. , 



THE CRYSTALLINE LENS. 



379 



Secondary Cataract and its Operation: Capsulotomy. — 

The term secondary cataract, as here used (compare p. 352), 
usually means a closure of the openmg which is present in the 
anterior capsule after the removal of a cataractous lens, along 
with a thickening of the capsule in some of the cases, by which 
an impediment is offered to the rays of light in passing through 
the pupil. The thickening may have pre-existed in the cap- 
sule, or it may be due to subsequent proliferation of the epi- 
thelial cells on the inner surface of the capsule. The 
term is also used with reference to those cases in which no 
central opening has been made in the capsule (peripheral cap- 
sulotomy), and where the latter causes imperfect vision. It 




Fig. 124. 

is also used in those cases where, after cataract extraction, an 
exudation in the pupil, consequent upon iritis, has occurred. 
Finally, and very incorrectly, it is applied to the cases which Fig. 
121 represents, in which, after suppuration of the wound with 
iridocylitis, the iris is dragged upwards, and the pupil is conse- 
quently obliterated. 

The most simple form of secondary cataract occurs as a very 
fine cobweb-like membrane — the capsule of the lens — extending 
over the whole area of the pupil, which can often only be dis- 
covered by careful examination with oblique illumination. It 
may not cause any trouble of vision until some months after the 
extraction, when some thickening of it may have taken place. 



38o DISEASES OF THE EYE. 

It is a simple matter to make a rent in this delicate membrane with 
a discission needle. 

Where there are thick opacities in the capsule, or inflamma- 
tory exudation into the pupil, with, probably, adhesions of the 
iris to the pupillary membrane, extraction of the latter has 
been proposed and practiced, but is associated with so much 
danger, from the unavoidable dragging on the ciliary body and 
iris, that the proceeding is not often employed. 

Sir W. Bowman's Method, with two needles, is here much 
preferable. The point of a discission needle is passed through 
the inner quadrant of the cornea, and into the center of the opac- 
ity (Fig. 124), and then, with the other hand, a second needle 
is passed through the outer quadrant of the cornea, and into the 
membrane, close beside the first needle. The points of the 
needles are now separated from each other by approximation of 
their handles, and in this way a hole is made in the membrane. 

A very small opening in the capsule, if quite clear, is sufficient 
to establish good vision. 

Noyes' Method. — A Graefe's cataract-knife is entered in the 
horizontal meridian of the cornea at its temporal margin, and a 
counterpuncture made in the same meridian at the inner corneal 
margin. The point of the knife is now withdrawn into the an- 
terior chamber, and made to puncture the secondary cataract, and 
is then removed from the eye. Two blunt-pointed hooks are 
then entered into the anterior chamber, one through each corneal 
puncture, and the point of each passed through the opening in 
the membrane made with the knife. By traction on the hooks 
this opening is enlarged, without any dragging on the iris or 
ciliary body. 

Knapp's Method. — Knapp has designed a needle-knife for 
dividing the capsule. This instrument has a blade 4 1-2 mm. in 
length. It cuts on one side only, and the blade and the evenly 
rounded shaft are so proportioned that the shaft fills exactly 
the opening made by the blade, and consequently the needle can 
be moved within the anterior chamber in every direction, without 
escape of aqueous or bruising of the cornea. The instrument 
must be of the utmost sharpness in point and edge, so that it 
may cut, and not tear. The point of the needle-knife is en- 
tered through a thin part of the capsule, and an opening is cut 
in it, hard and inelastic bands being avoided. 

Iridotomy. — For the cases as in Fig. 121, where the iris forms 



THE CRYSTALLINE LENS. 381 

a complete and tightly stretched curtain across the pupil, iri- 
dectomy is the operation which readily suggests itself. In very 
few cases, however, does it give a satisfactory result, owing to 
the inflammatory products which lie behind the iris, and which 
close up any artificial pupil by their proliferation, which is set 
going afresh by the dragging of the iris with the forceps. Re- 
peated iridectomies may finally produce a clear pupil, but iri- 
dotomy, in which there is no dragging of the iris, is a better 
operation in these cases. 

There are several modes of performing iridotomy, that of 
de Wecker being the best. A vertical incision having been made 
in the cornea, about 3 mm. long, and the same distance removed 
from its inner margin, the closed blades — one of which has a 
sharp point — of de Wecker's forceps-scissors are passed into 
the anterior chamber. The blades are then opened, and the sharp 
point of one of them is forced through the stretched iris, and 
some 3 or 4 mm. behind it. By now closing the blades the 
tightened iris fibers are cut across, and on their retraction 
a central clear pupil is formed in the iris and retro-iridic 
tissue. 

Dislocation of the Crystalline Lens. — This may be congeni- 
tal, and due to arrested development of the zonula of Zinn ; or it 
may be the result of disease, such, for example, as anterior sclero- 
chorioiditis ; or it may be caused by a blow or other trauma. 

The dislocation may be partial or complete. In the former 
case it is often so slight as to be discoverable only when the 
pupil is widely dilated, the margin of the lens becoming then 
visible as a curved black line, in some one direction, by aid of the 
ophthalmoscope mirror ; or the displacement may be so great as 
to bring the margin of the lens across the center of the undilated 
pupil, in which case one part of the eye will be highly hyper- 
metropic, while in another part it will be myopic. Complete 
dislocation may take place into the anterior chamber, into the 
vitreous humor, or even under the conjunctiva, if the sclerotic 
have been ruptured. 

The symptoms in partial dislocation are those of loss of power 
of accommodation, and monocular double vision. Iridodonesis 
(i. e., trembling of the iris when the eye moves) is present, as a 
rule, in consequence of the loss of support provided by the lens. 
In complete dislocation the symptoms are those of aphakia — i. e., 
extreme hypermetropia, and want of power of accommodation. 



382 DISEASES OF THE EYE. 

Treatment. — In partial dislocation it is rarely that any treat- 
ment can be of service. The prescribing of spectacles suited, 
so far as it is preferable, to the faulty refraction is indicated. 
In complete dislocation of the lens into the anterior chamber, 
its extraction is usually required, especially if it cause symptoms 
of irritation. Dislocation into the vitreous humor is generally 
unattended by irritation ; but when the latter does arise, removal 
of the lens by aid of a spoon, through a peripheral corneal in- 
cision, has to be attempted. 

Lenticonus is a very rare congenital anomaly of the lens, in 
which its anterior surface, or, still more rarely, its posterior sur- 
face, is cone-shaped. 

Aphakia(<^,/?m'.; cpaxo^, a lentil, lens), or Absence of the Crys- 
talline Lens. — The condition of the emmetropic eye after the 
removal of a cataract is one of high hypermetropia, and the power 
of accommodation is wanting. Consequently, in order that the 
eye may have the best possible sight for distant objects, a high 
convex glass has to be experimentally found to suit it, and 
stronger lenses must be prescribed for shorter distances. 

The degree of vision obtained varies considerably in different 
cases ; frequently V = |- is obtained, but V = -ys may be 
regarded as a satisfactory result ; and even lower degrees, which 
enable the patients to find their way about with comfort, are 
classed as successful operations. The vision often improves for 
some months after the operation, patients who at first had only 
■^ or so advancing up to f or f For writing, reading, 
etc., at about 25 cm., a still higher convex glass must be provided. 
If the correcting lens for distant vision be -\- 10 D, its power, for 
vision at 25 cm., must be increased by the lens which would 
represent the amplitude of accommodation from infinite distance 
up to 25 cm. This lens is 4 D (because V/ = 4) ; therefore 
+ 14 D is the lens required. With these two lenses most pa- 
tients are satisfied. For distinct vision at middle distances they 
learn to vary the power of the lenses by moving them a little 
closer to, or farther from, the eye ; but, if necessary, a lens can be 
prescribed for distinct vision at any desired distance. 

In the case of hospital patients one is often obliged to select the 
+ glasses in a fortnight or three weeks after the operation, but 
the result is more satisfactory when the selection can be post- 
poned for six weeks or two months. Permanent wearing of the 
+ glasses should not be permitted until all redness of the eye 



THE CRYSTALLINE LENS. 383 

has passed off, and this varies in different cases. Until then, 
alsOj dark protection spectacles should be worn. 

In the majority of cases, after cataract operations, the best 
vision is not obtained until a certain degree of astigmatism is 
corrected. This astigmatism is caused by a flattening of the 
vertical meridian of the cornea, due to the incision at its upper 
margin, and hence it is against the rule (see p. 50). An obliq- 
uity in the incision often produces an obliquity in the principal 
meridians of the astigmatism. The degree of astigmatism varies, 
and may be very high. It rapidly reaches its maximum after the 
operation, and then gradually diminishes for weeks or months, 
and in some cases completely disappears ; hence it is that glasses 
for permanent use can be better prescribed a month or two 
subsequently to the operation. 

For an account of Erythropsia after cataract extraction see 
chap. xvii. 

References. 

'"Trans. Ophthal. Soc, U. K," 1883, p. 79. 
^ " Archives of Opthalmology," xi. 3. p. 349. 
^ " Ophthalmic Review," 1889, p. 235. 
* " Gazette Hebdomadaire," 1875, No. 35. 
^ " Archives of Ophthahnology and Otology," vi. p. 545. 
® " Von Graefe's Archiv," xxxviii. 4. p. i. 
'Ibidem, li. p. 199. 

^ " Trans. Ophth. Soc, U. K.," x. p. 108; and "Anatomy and Pathology 
of the Eye," p. 107. London, 1896. 



CHAPTER XIV. 
DISEASES OF THE VITREOUS HUMOR. 

Purulent Inflammation of the Vitreous Humor (to which, 
unfortunately, the name pseudo-gHoma is sometimes appHed) 
occurs only as the result of perforating injuries, or of the lodg- 
ment of a foreign body, or as an extension of a purulent process 
from the chorioid (p. 263). 

O phthalniosco pically , a purulent deposit in the vitreous humor 
gives a yellowish reflection. It is to be distinguished from a 
somewhat similar appearance in glioma of the retina by the his- 
tory, by its early complication with more or less severe iritis, by 
the very frequent retraction of the periphery of the iris, with 
bulging forwards of its pupillary part, and by the diminished 
tension of the eye, while a lobulated appearance is not so usual 
in it as in glioma. Again, in glioma the vitreous humor remains 
clear, while in this disease it is hazy. 

The condition, if at first confined to the vitreous humor, soon 
extends to the surrounding tissues, and usually leads to panoph- 
thalmitis and complete destruction of the eye. 

Inflammatory Affections of the Vitreous Humor, other than 
the purulent form, are for the most part the consequence of 
diseases of the chorioid, ciliary body, or retina, and display 
themselves as opacities of various kinds. These are either cells 
derived from the primarily diseased tissue, or they are second- 
ary changes (connective tissue development), the result of this 
cellular invasion. 

The chief Varieties of Vitreous Humor Opacities are: \i) 
The Dust-like Opacity so characteristic of syphilitic disease of 
the retina and chorioid. It may occupy the entire vitreous humor, 
but is frequently confined to the region of the ciliary body, or to 
that of the posterior layers of the vitreous humor. (2) Flakes 
and Threads. These occur with chronic affections of the chorioid 
or ciliary body, and may be the result also of hemorrhages into 
the vitreous humor. They invade every portion of the humor. 
(3) Membranous Opacities, which are rare, and are probably 

384 



THE VITREOUS HUMOR. 385 

the result either of extensive hemorrhagic extravasations or of 
chorioidal exudations. 

Hemorrhages into the vitreous humor are not uncommon, and 
are the result of certain diseases of the retina and chorioid, which 
are accompanied by hemorrhages in those membranes. They are 
common in old people, but very large hemorrhages also occur in 
young adults (see Apoplexy of the Retina). They are also 
caused by blows on the eye, which rupture the chorioidal or ret- 
inal vessels. Most of the alterations occurring in the vitreous 
humor are attended with, or give rise to, fluidity of it, and may 
lead to detachment of the retina. 

The Diagnosis of opacities in the vitreous humor is made 
with the ophthalmoscope mirror and a not very bright light, 
or with the plane mirror. If a very bright light and a concave 
mirror be employed, the finer opacities will not be readily seen. 
The pupil being , illuminated, the patient is directed to look 
rapidly in different directions, when the opacities will be seen 
to float across the area of the pupil, as they are thrown from 
one side of the eye to the other. 

Opacities in the vitreous can be distinguished from those in 
the lens by the fact that the latter are fixed, and are arranged 
mostly in a radiating manner. Opacities which lie behind the 
center of curvature of the cornea, as examined with the ophthal- 
moscope mirror, seem to move in the opposite direction when 
the patient moves his eye ; while those which lie in front of that 
point move in the same direction as the eye. Therefore opacities 
in the lens and anterior part of the vitreous humor, about 0.6 
mm. behind the lens,"^ will move in the same direction. 

Another and very fine method for the detection of delicate 
opacities in the vitreous is by placing a high -|- lens, say -j- 10 D, 
behind the ophthalmoscope mirror, and then going close to the 
eye, as in the examination of the upright image. Minute opac- 
ities will then be seen as black dots floating in the vitreous 
humor. 

When the vitreous humor is full of blood, no red reflex can 
be obtained with the ophthalmoscope, and the pupil looks quite 
black. By focal illumination we can observe, in this case, that 
the lens is perfectly clear, and sometimes the red color of the ex- 
travasated blood can be seen behind it. 

* Radius of curvature of cornea, 7.829 mm. Distance from anterior 
surface of cornea to posterior surface of lens, 7.2 mm. 



386 DISEASES OF THE EYE. 

The ophthalmoscope does not always detect changes in the 
chorioid or retina, when they are opacities in the vitreous; and 
in many such cases we are led to the belief that the diseased 
changes in the chorioid or retina are too fine to be seen with the 
ophthalmoscope, or that they are situated in the region of the 
ciliary body which is out of view. 

Vision is affected by opacities in the vitreous humor in pro- 
portion to their density, and to the extent to which the vitreous 
humor is occupied by them. The patients often observe them as 
floating positive scotomata in their field of vision. These en- 
topic appearances are caused by the shadows of the opacities 
thrown on the retina. 

The Prognosis depends on the cause of the opacities. Small 
hemorrhagic extravasations in young people are readily absorbed, 
but are liable to recur. The dust-like opacities accompanying- 
specific retinitis are also favorable for absorption, while exten- 
sive hemorrhages in older people, and the flake and thread 
opacities, frequently remain as permanent obstructions. More- 
over, by shrinking, many of the more organized opacities give 
rise to detachment of the retina from the chorioid, and conse- 
quent blindness. 

Treatment consists, above all, in that for the exciting cause. 
Besides this, Heurteloup's artificial leech, or dry cupping on the 
temple, is most useful ; and in many cases, soon after the applica- 
tion, a marked clearing up of the vitreous is apparent. Pilocarpin 
hypodermically is worthy of trial. In one case von Graefe oper- 
ated on membranous opacities by tearing them with a needle, and 
with a successful result. 

Mouches Volantes, Muscae Volitantes, and Myodesopsia 
{fxviay a fly ; oipi?, seeing) are terms applied to the motes which 
people frequently see floating before their eyes, but which do not 
interfere with the acuteness of vision, nor can the ophthalmoscope 
detect opacities in the vitreous humor, or any other intra-ocular 
disease. These motes are most apparent when a bright surface, 
such as a white wall or the field of a microscope, is looked 
at. Mouches volantes have no clinical importance. Those an- 
noyed with them should be strongly recommended not to look 
for them, as in that case others are very apt to become visible. 
They depend, probably, upon minute remains of the embryonic 
tissue in the vitreous humor. 

Fluidity of the Vitreous Humor, or Synchysis ((Jvv^ to- 



THE VITREOUS HUMOR. 



387 



gether; jfc^, to pour) is not rare. It can only be diagnosed 
with certainty when the humor contains floating opacities. Low 
tension of the eyeball does not alw^ays indicate fluidity of the 
vitreous, although soft eyeballs nearly always contain fluid 
vitreous humor. Trembling of the iris is also no sign of fluid 
vitreous, but merely indicates that the iris is not supported in the 
normal way by the crystalline lens. Defective zonula of Zinn, 



1 







Fig. 125. 



however, is often caused by, or Is a concomitant of, fluid vitreous, 
and, by causing displacement of the lens, would allow trembling 
of the iris. 

The Causes of synchysis are chorioiditis and staphyloma of the 
chorioid and sclerotic, and it also occurs as a senile change. 

Synchysis Scintillans is a fluid condition of the vitreous hu- 
mor, with cholesterin and tyrosin crystals held in suspension in 
it. The ophthalmoscopic appearances are very beautiful, re- 



388 



DISEASES OF THE EYE. 



sembling a shower of golden rain. A satisfactory explanation 
for the occurrence of these crystals in this position has not yet 
been given. They usually occur in old people, and seldom 
cause any marked deterioration of vision. 

Fluidity of the vitreous humor is not, per se, a condition of 
serious import, unless the eye come to be the subject of an opera- 




FiG. 126, 



tion involving an incision in the corneo-sclerotic coat, when it 
renders prolapse of the vitreous more liable to take place. 

Foreign Bodies in the Vitreous Humor and Interior of the 
Eye in General. — One of the most common and most serious 
accidents to the eye is perforation of the sclerotic, or of the cornea 
and crystalline lens, by a small foreign body (shot, morsel of 
iron, copper, stone, or glass), which then lodges somewhere in 
the interior of the eye, very frequently in the vitreous humor. 

In cases where the ophthalmoscope fails us, owing to ex- 



THE VITREOUS HUMOR. 



389 



travasation of blood, etc., it is sometimes not easy to say whether 
the foreign body be in the eye, or whether it may merely have 
punctured the sclerotic without passing through it, and then fallen 
to the ground. If it be known to have been a small foreign 
body, which has flown against the eye with force, the prob- 
abilities are that it is lodged in the eye. 

But, if the case be seen immediately, or soon after the accident, 




Fig. 127. 



and there be no intra-ocular hemorrhage to obscure our view, the 
foreign body may frequently be detected with the ophthalmoscope 
in the vitreous humor as a dark or glittering body, according 
to its nature, and focal illumination with dilated pupil will often 
help us to discover a foreign body situated in the anterior part 
of the vitreous humor. Or, if it cannot be seen, an opaque 
streak through the vitreous humor, one end of which corresponds 



390 DISEASES OF THE EYE. 

with the sclerotic wound, may indicate the track taken by a 
foreign body. 

In case the foreign body has perforated the cornea, and reached 
the vitreous humor through the circumlental space, a counter- 
opening will be found in the iris ; while, if it be supposed to have 
passed through the cornea and lens, the openings both in the 
anterior and posterior capsule of the lens should be sought for. 

Of recent years the Rontgcn Rays have been very success- 
fully employed in determining not only the presence, but also 
the exact position of foreign bodies in the eyeball and orbit, and 
to Mackenzie Davidson is due the credit of having devised a most 
complete and- practical method for the application of the rays, 
and for the obtaining of skiagraphs. It is as follows : 

The patient sits upon a chair in an upright position with his 
head fixed in a headpiece (clamped to a table) to keep it steady, 
while at the same time a photographic dry plate can be placed 
against the temple on the side of the eye which is to be photo- 
graphed. 

Fig 125 show^s the patient in position for having his left eye 
skiagraphed. (If the right eye is to be photographed he sits 
the other way, so that this headpiece is constructed for taking 
either the right or left eye.) 

Fig. 126 is an enlarged picture of a patient's head in position 
for taking the right eye. The back of the head rests against 
a board, and another board, with a thumbscrew sliding in a 
groove, serves to press and fix his head laterally against two 
stretched piano-wires, behind which again the photographic plate 
is placed. The chin is supported on an adjustable projec- 
tion. 

Fig. 127 is a side view of the same patient. The stretched 
piano-w^ires are shown. The patient, while the skiagram is 
iDeing taken, is made to fix his gaze on a distant object, so that 
his optic axis is parallel to the horizontal wire. Previously, a 
small piece of lead wire, exactly i cm. long, is placed on the 
lower eyelid, and secured by tw^o strips of adhesive plaster, 
and the relative position of the point of the wire (nearest the 
eye) is carefully noted in relation to the cornea (e. g., so many 
millimeters vertically below the center of the cornea, or so 
many millimeters vertically below any corneal scar which may 
happen to be present) ; also whether the point is on a level 
with a vertical line from the center of the cornea (as it usually 



THE VITREOUS HUAIOR. 391 

is), or how far behind or in front of this plane. These are all the 
adjustments necessary to be made with the patient. 

Before the patient is placed in position, the Crookes tube 
is adjusted, so that the fine point on the anode, from which 
the linear X-rays originate, shall be exactly opposite the point 
of intersection of the two stretched piano-wires. When the tube 
is worked by the coil, this point shows as a bright incandescent 
spot on the anode, if it be of osmium ; and by means of a fixed 
" sight," placed on this side of the wires, the tube can be so ad- 
justed that this point is exactly opposite the intersection of the 
wires. The distance is carefully noted ; it is usually 28 to 30 
cm. The tube-holder is fixed to a bar of wood, w^hich slides 
horizontally, and by means of marks placed on the bar itself and 
upon the edge of the groove in which it slides, it can be displaced 
in a plane exactly parallel to the horizontal wire. It is to be 
displaced 3 cm. to one side of the vertical or zero point. Then 
a photographic plate, protected, as usual, in black paper, is placed 
against the wires (see Fig. 127), and an exposure given of from 
ninety seconds to two minutes. With exceptionally good osmium 
tubes ten seconds is enough. The tube is then displaced 3 cm. 
to the other side of the zero point — the photographic plate hav- 
ing been removed and a fresh one put in its place — and a second 
similar exposure is given. The result is two negatives taken from 
two points of view 6 cm. apart. 

A transparent sheet of thin celluloid has two cross-lines marked 
upon it at right angles to each other. One side is varnished, 
so that it will readily take pencil marks. Immediately after 
development and fixing, this sheet of celluloid is placed over 
the film side of the negative, so that its two lines are exactly 
superimposed upon the white lines left by the wires in the head- 
piece ; while fimily held in position, the shadow of the leaden wire 
or landmark, placed on the lower eyelid, is carefully traced. Then 
the foreign body, or foreign bodies, is, or are, traced in the same 
way. This process of tracing is repeated with the other nega- 
tive. The result is that upon the sheet of celluloid two tracings 
of the leaden landmark wire, and two tracings of the foreign 
body, side by side, are obtained. 

This celluloid tracing is now placed upon the horizontal glass 
stage of the Cross-Thread Localizer. The latter has two fine 
silk threads coming from two points, which are so adjusted as to 
occupy relatively the two positions occupied by the anode of the 



392 DISEASES OF THE EYE. 

Crookes tube, and to be at the same distance from the celluloid 
tracing, and also in the same relative position to the cross-lines 
that the anode of the Crookes tube had to the photographic plate 
and to the cross-wires of the headpiece, when the photographs 
were being actually taken. 

The silk threads are now used to trace the linear paths of the 
X-rays. The intersection of the two threads fixes the position of 
the object in space.^ Its geometrical relations to the known 
data can then be measured. First, the three co-ordinates of the 
known point are ascertained, then the three co-ordinates of the 
unknown foreign body, and then, by simple subtraction, the 
minor co-ordinates are obtained, and thus the position of the 
foreign body is accurately determined. The surgeon is enabled 
to say how far horizontally inwards or outwards the foreign 
body lies from the point of the landmark lead wire; from that 
point how far vertically upwards or downwards it lies; and, 
finally, how far directly backwards, parallel to the visual axis, 
it is situated. If care be taken, the position of a foreign body, 
however small, can be ascertained with great accuracy by this 
method. Its size also can be discovered. Moreover, the two 
negatives are stereoscopic, so that, when viewed either in a 
Wheatstone's reflecting stereoscope, or by converging the optic 
axes, and so fusing the pictures, a single picture in relief is seen, 
showing the relative position of the parts in a very beautiful 
manner. 

The Sidcroscope ^ is an instrument devised by Asmus for the 
detection of the presence of atoms of steel or iron in the eye ; but 
the first suggestion for it was given by T. R. Pooley, of New 
York, many years earlier. It consists in a magnetic needle hung 
by a fine thread, and so mounted that, when it is brought close to 
the eye containing the foreign body, its deflections can be read 
by means of an astronomical telescope which is attached. The 
sideroscope is also used for ascertaining the position of the 
foreign body, which is nearest to the part where the deflection 
of the needle is greatest. This, of course, is only an approximate 
localization. 

The danger of leaving a foreign body in the eye is great. It 
is rarely that, whether it remains free or, as sometimes happens, 
becomes encapsuled, it is tolerated permanently in any part of the 
interior of the eye, and that event should never be reckoned on 
in the treatment of such a case. 



THE VITREOUS HUMOR. 393 

As a rule foreign bodies in the vitreous, or elsewhere within 
the eye, soon produce violent inflammatory reaction. This oc- 
curs, either by reason of infective micro-organisms being intro- 
duced into the eye with the foreign body, or it may be caused by 
the oxidization of the foreign body, when, as is most common, it 
is of iron or copper. The form of inflammation may be either a 
plastic or purulent uveitis, in the latter case with purulent infiltra- 
tion of the vitreous humor and hypopyon. 

An eye which contains a foreign body that is not, or can- 
not be, at once removed, may be regarded as lost; and such an 
eye becomes, moreover, one of the surest sources of sympathetic 
ophthalmitis. 

It is, consequently, of the utmost importance to remove every 
foreign body from the interior of the eye if possible, where there 
is a reasonable prospect of saving the eye, even partially, by so 
doing — and this with the least possible delay ; or, carefully to 
watch the eye, and at any sign of inflammatory reaction to ex- 
cise the eyeball. Indeed, in view of the fact that this inflam- 
matory reaction almost invariably comes on sooner or later, I 
should be inclined to excise most of these eyes, as soon as it has 
been decided that the foreign body cannot be extracted. 

Removal of the Foreign Body is very often an extremely difli- 
cult and disappointing undertaking, but it should always be at- 
tempted when, being neither steel nor iron, it is visible within 
the eye, so that its position can be determined with the ophthal- 
moscope or by focal illumination, and when it seems that the 
eye may be saved, at least to some extent. 

The introduction of the magnet for the removal of fragnaents 
of iron or steel has made it unnecessary that they should in every 
case be visible, and here the chances of success have been much 
enhanced since the foreign body can be accurately localized by 
the Rontgen rays. In all these operations it is necessary that 
the patient should be deeply under the influence of an anesthetic, 
in order that as little vitreous humor as possible may be lost. 
And, again, strict aseptic measures must be observed, lest by our 
operation the very form of mischief be produced which it is our 
desire to avert. 

There are several methods of proceeding. Atoms of glass, 

copper, stone, etc., may sometimes be removed through an 

incision in the sclerotic which is either an enlargement of the 

opening made by the foreign body, or is a special one, at a point 

33 



394 DISEASES OF THE EYE. 

more nearly corresponding to the actual position of the latter in 
the eye. This incision should lie between two recti muscles, 
should have an antero-posterior direction, and, in order that it 
may gape but little, should be a puncture with a broad keratome. 
Prolapse of the vitreous is then produced by pressure on the 
eyeball, and the foreign body is evacuated. 

This method should only be tried when the foreign body is 
situated in the periphery of the vitreous, and towards the equator 
of the eye, where the opening for its exit can be made in its im- 
mediate neighborhood ; but the proceeding is often attended 
with disappointment, much vitreous being lost, while the foreign 
body remains in the eye. 

Or, a forceps is passed in through the opening, and while 
the foreign body is kept in view with the ophthalmoscope it is 
seized and drawn out. This plan is also unsatisfactory, as, loss 




Fig. 128. 

of vitreous occurring, the cornea becomes flaccid, and the view 
of the foreign body is soon obscured. 

Again, some surgeons prefer to make their opening not close 
to the foreign body, but exactly at the opposite side of the eye- 
ball, by which means they can often reach the foreign body with 
greater ease, and with less injury to the tissues. 

The magnet, thanks to M'Keown, of Belfast,^ has of late years 
come into use for the removal of fragments of steel and iron 
from the interior of the eye, and especially from the vitreous hu- 
mor. M'Keown used a permanent magnet ; but electro-magnets 
are those now employed for this purpose, the instruments of 
Hirschberg "* and of Simeon Snell ■' being the most suitable. Fig. 
128 represents Snell's instrument in two-thirds its actual size. 
It is a core of soft iron, around which is placed a coil of insulated 
copper wire, the whole inclosed in an ebonite case. To one ex- 
tremity of the instrument are attached the screws to receive the 



THE VITREOUS HUMOR. 



395 



connections of a small accumulator. At the other extremity the 
core projects just beyond the ebonite jacket, and is tapped, 
and into it screws the point. Points of various kinds or shapes 
can be adjusted to the magnet, according to the case to be dealt 




Fig. i2( 



with. A point having been passed through the sclerotic open- 
ing, it is advanced towards the foreign body, when the latter 
adheres to it, and is drawn towards the wound. To prevent too 
much stirring up of the vitreous, which might lead to its shrink- 
age, with consequent detachment of the retina, it is desirable. 



39^ DISEASES OF THE EYE. 

previously to introduction of the magnet point, to divide the 
vitreous w^ith a Graefe's knife until close to the foreign body. 
Much care is required in drawing the foreign body through 
the opening, lest it be rubbed off the point in its passage. 
A forceps is generally used at this part of the proceeding, either to 
dilate the wound, or to seize the foreign body and extract it. 

Haab's Giant Electro-Magnet^ (Fig- 129) is also used for 
extracting morsels of iron or steel from the eye. It is an im- 
mense and very powerful magnet, which is placed close to the 
eye. Care is required in its use, lest even more injury be done 
to the delicate tissues of the eyeball by the foreign body in its 
passage towards the magnet than by its entrance into the eye. 

As a rule, Haab recommends that the center of the cornea, in 
the first instance, be brought opposite and close to the point of the 
magnet, for by so doing entanglement of the foreign body in the 
ciliary processes, from which it is not easy again to disengage it, 
may best be avoided. Foreign bodies which are in the vitreous hu- 
mor, or which are not too firmly fixed in the retina, slide round 
the lens and bulge the iris forwards. As soon as this occurs the 
current is turned off, and the patient's head withdrawn from the 
magnet. By a suitable turning of the patient's head and eye, the 
latter being again approached to the magnet and the current 
turned on, the foreign body is drawn from behind the iris, through 
the pupil, which has been well dilated with atropin and cocain, 
and into the anterior chamber. Should it not be possible to get 
the foreign body away from behind the periphery of the iris with 
the magnet, an iridodialysis may be formed with a keratome, 
and the foreign body drawn away with a Snell's magnet or with 
a forceps. It must not be attempted to draw the foreign body 
by the magnet through the iris, or the latter may be partially or 
entirely pulled away. Having got the foreign body into the an- 
terior chamber through the pupil, an incision with a Graefe knife 
is made in the cornea, if possible without allowing the aqueous 
humor to flow away, and through the incision the sharp point 
of the giant magnet is passed, and the foreign body extracted. 
Even foreign bodies which enter through the sclerotic are best 
removed through the anterior chamber. When the foreign body 
is firmly fixed, it may often be loosened by rapid turning on and 
off of the current, or it may first be drawn towards the equator, 
and then towards the anterior chamber. 

Cysticercus in the Vitreous Humor is not of rare occurrence 



THE VITREOUS HUMOR. 397 

in some parts of Germany, but there have not been many such 
cases observed in the British Isles. Hill Griffith/ however, has 
published so many as seven cases from Manchester. 

The original seat of the entozoon is usually beneath the retina 
(see chap, xv.), through which it breaks to reach the vitreous 
humor; but it also sometimes makes its first appearance in 
the vitreous. It is recognized by its peculiar, somewhat dumb- 
bell shape, its iridescence, and its peristaltic motions. The 
vitreous humor often becomes full of peculiar membranous opac- 
ities, as a consequence of the presence of the cysticercus. 

Treatment. — Removal by operation. The prospects for the 
eye are very much worse than in the case of a subretinal cysti- 
cercus. 

Blood- Vessels are sometimes formed in the vitreous humor. 
They spring from the retinal vessels, often in connection with 
connective tissue formations which accompany hemorrhages ; but 
sometim.es small loops arise in the neighborhood of the disc, with- 
out any hemorrhagic disease. 

Persistent Hyaloid Artery. — In intra-uterine life the hyaloid 
artery is a prolongation of the central artery of the retina, and 
runs from the papilla to the posterior surface of the crystalline 
lens. It completely disappears prior to birth, except in those 
rare cases where it remains as an opaque string, which may 
stretch the whole way from papilla to lens, or may extend only 
part of the way. It is then thrown into wave-like movements 
by the movements of the eyeball, and is easily recognized with the 
ophthalmoscope. It does not usually cause any disturbance of 
vision. 

Detachment of the Vitreous Humor from the Retina, 
although probably a common diseased condition, cannot as yet 
be recognized with certainty during life, and rarely becomes 
the immediate cause of blindness. Its danger lies in its lia- 
bility to bring about detachment of the retina. 

Detachment of the vitreous may be either idiopathic or due 
to trauma. In the idiopathic cases chronic chorioiditis is the 
primary disease, which gives rise to a change in the fine con- 
nective tissue elements of the vitreous, with consequent shrinking 
of this body. Yet, with the ophthalmoscope, the chorioid may 
seem normal ; and, moreover, although floating opacities may 
be present in the vitreous chamber, yet it is quite possible for a 
perfectly clear vitreous to be detached. 



398 DISEASES OF THE EYE. 

The condition occurs in connection with high degrees of my- 
opia, where chorioiditis is also common, and is probably the most 
important factor in the production of the detachment of the retina, 
so frequent in these eyes. Anterior staphyloma, hemorrhages 
into the vitreous humor, and neoplastic growths between the 
vitreous and retina also gives rise to detachment of the vit- 
reous. 

Detachment of the anterior portion of the vitreous occurs in 
many cases of iridocyclitis. 

With regard to traumatic cases, all perforating injuries at- 
tended with loss of vitreous, including cataract operations — and 
sometimes, when the wound is in the sclerotic, without loss of 
vitreous — are liable to be followed by detachment of the vitreous. 

I observed a case ^ in which detachment of the vitreous was 
the chief lesion in the eye, and was the cause of blindness, the 





Fig. 130. 

vision being reduced to perception of light. The detachment had 
probably been brought about by an idiopathic hemorrhage from 
the ciliary body into the anterior part of the vitreous. It lay 
(Fig. 130) immediately behind the lens and in contact with it, 
and presented the appearance of a grayish opacity, very like a 
detached retina but for the absence of retinal vessels. Suspi- 
cion of an intra-ocular tumor existing, the eye was removed. The 
vitreous lay against the ciliary body and lens, while the vitreous 
chamber was filled with serous fluid, and the retina was in its 
normal position. In the retina, towards the ora serrata, there 
were a few minute hemorrhages. 

References. 

^ " British Medical Journal," January i, 1898. 

^ " Das Sideroskop und seine Anwendung." Wiesbaden, 1898. 

^"Brit. Med. Journal," 1874, vol. i. p. 800. 



THE VITREOUS HUMOR. 399 

* " Centralblatt fur prak. Angenheilkunde," 1879, p. 380, 
^ " The Electro-magnet," etc. London. 1883. 

^ " Bericht. d. Ophthalmologischen Gesellschaft." Heidelberg, 1892. 
Ibidem, 1902. " Klin. Alonatsblatter f. Angenheilkunde," 1902, p. 193. 
' " Trans Ophthal. Soc, U. K.," xxvii. p. 220. 
^Ibidem, ii. p. 41. 



CHAPTER XV. 

DISEASES OF THE RETINA. 

Diseases of the retina may, for the purpose of description, be 
conveniently grouped as follows : Alterations in Vascularity, In- 
flammation, Atrophy, Diseases of the Blood- Vessels, Injury by 
Strong Light, Tumors, Parasitic Disease, Detachment, and Trau- 
matic Affections. 

Alterations in the Vascularity of the Retina. 

Hyperemia and Anemia of the retina, due to changes in the 
capillary vessels, cannot be seen with the ophthalmoscope, hence 
these terms are used to denote apparent enlargement or diminu- 
tion of the principal branches of the central vessels. Venous 
Engorgement may occur as a local condition, as in papillitis, 
retinitis, thrombosis of the central vein, or as part of general 
venous obstruction in cardiac and pulmonary diseases. Contrac- 
tion of the Arteries may also be due to local disease of the ves- 
sels (embolism, albuminuric retinitis, etc.) and spasm (malaria, 
quinin), or, more rarely, to diminished blood supply from gen- 
eral causes (cholera). The opposite conditions, namely, dimi- 
nution in the size of the veins, and enlargement of the arteries, 
are rarely noticeable. 

Inflammations of the Retina: Retinitis. 

Retinitis, in general, is characterized by the following ophthal- 
moscopic appearances : diffuse cloudiness, especially of the cen- 
tral portion of the fundus, due to loss of transparency in the 
retina, and consequent veiling of the chorioid ; the optic papilla 
becomes more or less congested, with indistinctness of its outline 
which in the erect image resolves itself into a delicate striation ; 
vascular engorgement, the retinal veins especially becoming en- 
larged and tortuous. The inflammation in some cases may sub- 
side at this stage, but as a rule hemorrhages and whitish exiida-- 
tions soon make their appearance. 

400 






THE RETINA. 401 

The various forms of retinitis are distinguished by the pre- 
dominance of some of the above signs, and also by the pecuHar 
appearance and grouping of the exudations. 

If the optic papilla be not merely congested, but also swollen, 
the condition is called Neuro-Retinitis. 

In some cases of retinitis the chorioid is also involved, and to 
these the name chorio-retinitis is given. 

Inflammation of the retina is rarely a local affection, being in 
most cases due to general diseases, and hence it commonly occurs 
in both eyes. 

Syphilitic Retinitis (or Syphilitic Chorioido-Retinitis). — In- 
herited or acquired constitutional syphilis is liable to induce a 
form of chronic diffuse retinitis. In the acquired disease it is a 
later secondary symptom, coming on between the sixth and eight- 
eenth month, often only in one eye. 

With the Ophthalmoscope a slight opacity of the retina is seen 
extending from the papilla some distance into the retina, and 
very gradually disappearing towards the equator of the eye. The 
papilla is but slightly hyperemic, while its margins are indistinct, 
like those of the moon seen through a light cloud. The artery 
is not generally altered, and the vein but slightly distended. 
Opacities in the vitreous humor are not uncommon. They may 
be membranous or thread-like, but a diffuse dust-like opacity, 
filling the whole vitreous humor, is almost pathognomonic of a 
syphilitic taint, and may create much difficulty in the ophthalmo- 
scopic diagnosis of the retinal affection. 

Disseminated chorioidal changes, in the form of small yellow- 
ish spots with pigmentary deposits, are very frequent, especially 
towards the equator of the eye. Many observers, indeed, hold 
that the whole process is primarily in the chorioid, and that the 
retina is only secondarily affected. Fine whitish dots and pig- 
mentary changes often occur about the macula lutea. 

Vision may be but slightly affected, but in the advanced stages 
it is usually much lowered. Central, or peripheral, or ring scoto- 
mata, or concentric defects of the field, are found. The 
scotomata are often positive — /. e., they can be seen by the patient 
as dark spots in the field. Night-blindness is a constant symp- 
tom, and the light-sense is enormously diminished. The patients 
sometimes complain of sparks or lights, which seem to dance be- 
fore their eyes, and occasionally also of a diminution in the size 
(micropsia) of objects, or of a distortion (metamorphopsia) of 
34 



402 DISEASES OF THE EYE. 

their outlines. The micropsia is beheved to be due to a separa- 
tion from each other of the elements of the layer of rods and 
cones by subretinal exudation. The image of an object then 
comes into relation with fewer of these elements, and hence the 
mental impression is that of a smaller object than is conveyed by 
the image formed in the sound eye, or on a sound part of the same 
retina. 

The Progress of the Disease is very slow, and is liable to re- 
lapses. In the late stages extensive pigmentary degeneration of 
the retina may come on, or disseminated chorioiditis. But if the 
cases come under suitable treatment in an early stage, a cure may 
often be effected. 

Treatment. — The only remedy which is of real value is mer- 
cury, and that in an early stage. It should be used in a protracted 
course of some weeks by inunction, combined at discretion with 
small doses of calomel internally. Perchlorid of mercury hypo- 
dermically, in 1-20 grain doses once a day, is also a suitable 
measure. If mercurialization be effected, it should not go fur- 
ther than a very slight stomatitis. Turkish baths, and the arti- 
ficial leech at the temple, may be employed as adjuncts to the 
treatment. When the mercurial course has been completed, iodid 
of potassium should be prescribed as an after-treatment. Com- 
plete rest of the eyes, and protection from strong light by dark 
glasses, are also necessary in this, as in many forms of ret- 
initis. 

Hemorrhagic Retinitis. — In this affection the retina con- 
tains a number of small hemorrhages. They occur chiefly be- 
tween the fibers of the inner layer, and consequently present a 
flame-like appearance as seen with the Ophthalmoscope. Any 
which lie in the outer layers are more apt to be round or irregular 
in shape. In addition to the hemorrhages there is diffuse opacity 
of the retina, anji sometimes white spots of degeneration. The 
papilla is often much swollen, and the retinal veins distended and 
tortuous, while the arteries are small; but these appearances, as 
well as the number of the hemorrhages, vary much in different 
cases. When there are but few hemorrhages, they are situated 
in the neighborhood of the papilla and macula lutea. The ap- 
pearances occasionally resemble those of albuminuric retinitis, 
but in the latter, as a rule, the proportion of white spots to hemor- 
rhages is greater than in this affection. Probably many cases 
described as hemorrhagic retinitis are due to thrombosis of the 



THE RETINA. 403 

central vein. (See p. 412.) In a small proportion of cases glau- 
coma (p. 340) comes on. 

Causes. — The affection is found most commonly in connection 
with cardiac disease — e. g., valvular insufficiency, and hyper- 
trophy of the left ventricle ; or with diseases of the vascular sys- 
tem — c. g., atheroma, and aneurysms of the large vessels. Where 
it is due to disease of the coats of the arteries, the ophthalmo- 
scope will occasionally reveal an arterial branch altered to the 
appearance of a white thread ; but usually the degenerative 
change does not interfere with the transparency of the vascular 
coats. In the majority of cases dependent on cardiac or vascu- 
lar disease the retinal affection is monocular. This, and the fre- 
quently sudden onset of the retinitis, suggests some second factor 
for its occurrence, probably multiple embolisms of the small 
branches of the central artery. Suppression of menstruation, 
or other wonted discharge — such as that from piles — has been 
observed as an immediate cause of hemorrhagic retinitis. 

A peculiar form of hemorrhagic retinitis is sometimes asso- 
ciated with secondary syphilis. In addition to the usual opacity 
of the retina in syphilitic retinitis, a portion of the retina is cov- 
ered with numbers of small round hemorrhages lying in the dif- 
ferent layers of the retina, while a connective tissue develop- 
ment is occasionally found in the nerve-fiber layer, in the form 
of white striae along the course of the blood-vessels. 

The disturbance of vision is considerable, especially if the 
neighborhood of the macula lutea be much involved. 

The Prognosis is unfavorable in severe cases of hemorrhagic 
retinitis. Relapses are common, while the ultimate tendency is 
towards atrophy of the retina and papilla. In very mild cases 
recovery may come about. 

The Treatment must be chiefly expectant, or directed, at most, 
towards procuring rest for the general system, or for the organ 
primarily at fault. Dry cupping on the temple, hot footbaths, 
and iodid of potassium internally may be employed. 

Retinitis Albuminurica occurs as a complication in many 
cases both of acute and chronic nephritis, and in the albuminuria 
of pregnancy. It is most common with the small granular kid- 
ney, but may attend any chronic form of Bright's disease, and 
occurs in 6 or 7 per cent, of these cases. 

The Defect of Vision in the chronic form, although often an 
early or even the first symptom, is never associated with an early 



404 DISEASES OF THE EYE. 

stage of the kidney disease, but ratlier with a late stage of it, and 
with dilated left ventricle. Both eyes as a rule are affected, al- 
though often not equally so. Vision is much lowered, and even 
perception of light may be wanting ; but the blindness is not al- 
ways all due to organic changes in the retina, being often largely 
the result of uremia. 

Ophthalmoscopic Appearances. — These are venous hyperemia 
and swelling of the papilla, and of the retina in its neighborhood ; 
hemorrhages on the papilla, and in the nerve-fiber layer of the 
retina; and round or irregularly shaped white spots in the retina, 
arranged in a zone around the papilla, some three papilla-diam- 
eters removed from it. These changes take place in the order in 
which I have enumerated them. The hyperemia and engorge- 
ment of the veins, often very great, become less according as the 
white spots become more developed. Near the macula lutea no 
very coarse changes usually occur; but fine white dots are found, 
with a star-like arrangement converging towards the macula. In 
some cases the spots spread out only on the inner side of the 
macula towards the papilla. The degree in which all these dif- 
ferent changes are present varies in different cases, no one of 
them being pathognomonic of the kidney affection, but rather the 
grouping of the whole picture being suggestive. Sometimes the 
papillitis is so intense as to simulate that formerly known as con- 
gestion papilla in cases of intracranial tumor; while the white 
spots are sometimes developed to such a degree as to become 
confluent, and to form one large white plaque. Again, the papil- 
litis, or white spots, or both, may be but slightly marked. The 
number and size of the hemorrhages are also liable to great varia- 
tion. Detachment of the retina has been observed in a few 
cases, and in some the hemorrhages burst into the vitreous 
humor. 

Some of the white spots are caused by fatty degeneration of 
the outer layers of the retina (the retinal vessels passing over 
them), others by hypertrophy of the nerve-fiber layer (the retinal 
vessels hidden by them). The fine dots about the macula lutea 
are the result of fatty degeneration of the inner ends of 
Miiller's fibers. Small aneurysmal dilatations of the arteries 
occur very occasionally. 

The connection between the renal and retinal affections is not 
known with certainty, but the theory that the latter is due to 
chronic uremia is probably correct. 



THE RETINA. 405 

Prognosis. — In these chronic cases the prognosis as regards 
the patient's Hfe is bad. The majority die within eighteen 
months or two years ; but if the general disease remains station- 
ary, or improves, or recovers, the retinal changes may improve 
or disappear, and may leave the retina with normal appearances 
and functions ; or the swelling, hyperemia, white spots, and 
hemorrhages may give place to optic atrophy, with diminution 
in size of the arteries, pigmentary alterations in the retina, and 
blindness. In the albuminuria of pregnancy, and in acute 
nephritis, the retinal complication may disappear with the renal 
disorder, leaving good vision. 

Treatment. — Dry cupping at the temple is about the only rem- 
edy which can be employed directly for the retinal affection, and 
I cannot say that it is of much use. Taking into consideration the 
serious import of this eye-symptom for the life of the patient, it 
is a question whether, in many cases of pregnancy with al- 
buminuric retinitis, abortion should not be resorted to, espe- 
cially if the pregnancy have still some months to run. But on the 
whole the prognosis is more favorable in the albuminuria of 
pregnancy than in interstitial nephritis. 

Retinal Affections in Diabetes. — There is no one condition 
of the retina characteristic of diabetes, although undoubtedly 
retinal affections occasionally do complicate it in an advanced 
stage. Small retinal hemorrhages, with fine changes in the form 
of glistening dots, about the macula lutea, somewhat similar in 
appearance to those which occur in Bright's disease, except that 
they rarely form the well-marked star, are perhaps the most 
common and suggestive appearances. In other cases retinal 
hemorrhages alone are found, and in others hemorrhagic retinitis ; 
while, again, the so-called typical appearances of Bright's disease 
may be presented. There are often opacities of hemorrhagic 
origin in the vitreous humor, and iritis may come on. 

Leber lays down the important rule that in all cases of retinal 
hemorrhages and of retinitis hemorrhagica the urine should be 
examined for sugar. 

Retinitis Leukemica. — In not more than one-third or one- 
fourth of the cases of leukocythemia does a retinal affection oc- 
cur, and it is not always of the same type. It may consist in a light 
diffuse retinitis, accompanied by some extravasations of pale 
blood ; while the blood-vessels are also pale, the veins being 
much enlarged, and rather flattened than overdistended, the 



4o6 DISEASES OF THE EYE. 

arteries small, and the chorioid of an orange-yellow color. Or, 
it may resemble a case of ordinary hemorrhagic retinitis. 

The Appearances most characteristic of the affection are: a 
pale papilla with indistinct margins ; slight opacity of the retina, 
especially along the vessels ; small hemorrhages ; roimd white, 
elevated spots up to 2 mm. in diameter, with a hemorrhagic halo, 
situated by preference towards the periphery of the fundus and at 
the macula lutea, but not at all, or only in very severe cases, in 
the zone between the macula and the equator of the eye. These 
white spots consist of extravasations of leukemic blood, the re- 
sults, probably, of diapedesis. 

Vision may be but little affected if the macula lutea be fairly 
free. Hemorrhage into the vitreous humor may cause complete 
blindness. 

Retinitis Punctata Albescens. — This disease commences in 
early childhood, or is perhaps congenital. It often occurs in 
more than one member of a family, and the parents are frequently 
blood-relations. The main symptom is night-blindness ; in good 
daylight central vision is usually not defective to any marked 
degree. The field of vision is contracted. Ophthalmoscopically 
the fundus is sprinkled over with innumerable small white dots, 
which, for the most part, are free from any pigmentary disturb- 
ance in their neighborhood. In some cases, towards the periphery 
of the fundus, signs of chorioidal atrophy are present. It is 
thought by some tliat this disease is related to retinitis pig- 
mentosa. 

Treatment is of no avail. 

Development of Connective Tissue in the Retina, or Reti- 
nitis Proliferans. — Extensive white striae, formed of connective 
tissue, are sometimes seen in the retina, and may even conceal 
the vessels and papilla. They are the result of hemorrhages, 
traumatic or otherwise, according to Leber, and of an inflam- 
matory process according to Manz, and are formed by prolifera- 
tion of Miiller's fibers and new growth of connective tissue. 
Hemorrhages in the retina, or in the vitreous humor, or in both, 
are generally present at some period. Vision is often but slightly 
affected, but the danger of recurrent intra-ocular hemorrhages 
renders the ultimate prognosis unfavorable as a rule. 

Treatment — Heurteloup's leech. lodid of potassium, or per- 
chlorid of mercury. Protection spectacles. 

Retinitis Circinata is a rare disease, first described by Fuchs.^ 



THE RETINA. 407 

It occurs in old people, chiefly women, and is characterized by 
very remarkable appearances. At the macula is a gray or yel- 
lowish cloudy patch, which may attain the size of the papilla, and 
sometimes presents hemorrhages on its surface; surrounding 
this, but separated from it by a healthy zone, is a ring composed 
of numerous closely set, small white spots, which are confluent 
in places. The sight gradually becomes much deteriorated. A 
large central scotoma develops, and vision is finally reduced to 
finger-counting centrally, although for a long time the peripheral 
field may not become contracted. Total blindness rarely re- 
sults. 

Purulent Retinitis is observed as the result of septic embolism 
of the retinal arteries in septicemia after surgical operations, etc., 
and very frequently in cases of metria, and it is usually, in the 
latter condition, a fatal sign. 

In an early stage the Ophthalmoscope shows a number of 
small hemorrhages in the retina, with general cloudiness of the 
retinal tissues, while the actual embolisms, which are usually mul- 
tiple, may not be visible. 

The inflammation makes rapid progress, soon destroying sight, 
and extending to the chorioid, iris, and vitreous humor, until 
finally panophthalmitis is reached. The retina is sometimes 
alone the primary seat of the embolic attack, and sometimes the 
chorioid is also involved. The embolisms are often little more 
than masses of micrococci. 

The retina becomes secondarily implicated in many purulent 
processes, which commence in other parts of the eye. 

Atrophy of the Retina. 

Atrophy, or degeneration, of the retina is characterized by 
diminution, or even complete obliteration, of the retinal vessels, 
accompanied by more or less atrophy of the optic papilla. It 
may be caused by severe forms of retinitis, and also by embolism 
or thrombosis. 

Retinitis Pigmentosa is a degenerative rather than an inflam- 
matory affection of the retina. It is extremely chronic in its 
progress, coming on most commonly in childhood, and often re- 
sulting in complete, or almost complete, blindness in advanced 
life. 

Vision is much affected, but the symptom most complained 



4o8 DISEASES OF THE EYE. 

of is night-blindness, due rather to defective power of retinal 
adaptation than to defective light-sense. The field of vision, 
moreover, becomes gradually contracted, until only a very small 
central portion remains ; so that, although the patient may still 
be able to read, he cannot find his way alone — a function for 
which the eccentric parts of the field are the most important. A 
ring scotoma in the field of vision is present in some cases. 
Finally, the last remaining central region becomes blind. 

The Ophthalmoscopic Appearances consist in a pigmentation of 
the nerve-fiber layer of the retina, which commences in the 
periphery, but not at its extreme limits, and in the course of 
years advances towards the macula lutea. The pigment is ar- 
ranged in stellate spots, of which the processes intercommuni- 
cate, so that the appearance reminds one of a drawing of the 
Haversian system of bone. Pigment is also deposited along 
the course of many of the vessels, hiding them from view. The 
degree of pigmentation varies much, and in some cases is quite 
absent, and the diagnosis then has to depend upon the other ap- 
pearances and on the symptoms. The papilla is of a grayish- 
yellow color, never white, and the vessels are very small. 

The chorioid is sometimes slightly affected, irregularity in 
its pigmentation being observable. At the posterior pole of the 
crystalline lens there is often a star-shaped opacity. 

Pathology. — The pigment in the retina is believed to wander 
into it from the pigment-epithelium layer. The other patho- 
logical changes in the retina consist in hyperplasy of its con- 
nective tissue elements, and thickening of the walls of the ves- 
sels at the expense of their lumen. 

The chorioidal vessels, too, are altered, owing to endarteritis, 
which causes hypertrophy of their coats, with more or less 
obliteration of their lumen. In fact, it seems probable that the 
primary seat of the diseased process is in the chorioid ; and that 
it is the changes in it which cause the pigment from the pigment- 
epithelium layer to wander into the retina. 

Causes. — Retinitis pigmentosa often affects more than one 
member of a family; and the patients, too, are frequently de- 
fective in intelligence or deaf and dumb. Many of them are 
the offspring of marriages of consanguinity, and in others an in- 
herited syphilitic taint is present, while in others no cause can 
be assigned. Other congenital defects, supernumerary digits, 
etc., are sometimes present. 



THE RETINA. 409 

Treatment is of little use. At best one may stimulate the 
torpid retina temporarily by hypodermic injections of strychnia 
or with the continuous current. 

Gyrate Atrophy of the Retina and Chorioid (Fuchs).^ — The 
disease, according to Fuchs, who has seen only a few cases, 
is apt to occur in more than one member of the same family, and 
in children whose parents are blood-relations. The first symp- 
tom appears in childhood as night-blindness. The optic papilla 
is atrophied, as in retinitis pigmentosa, and atrophy of the retina 
is shown by the narrowing of its vessels. The characteristic 
feature is the peculiar form of chorioidal atrophy. In a zone 
with the papilla for its center, and extending nearly to the latter, 
white atrophic dots with sharp margins form, and gradually in- 
crease in size, until they become confluent. The atrophy in- 
volves both the pigment epithelium and the stroma of the chorioid. 
The papilla is finally surrounded by a broad white girdle, from 
which it is separated by a band of normally colored fundus. The 
edge of the girdle towards the papilla is scalloped, because the 
separate rounded parts of which it is composed extend back- 
wards in varying distances, while the remains of the normal 
fundus project forwards between them in sharp processes. There 
is often, as in retinitis pigmentosa, a star-shaped posterior polar 
cataract. In addition to the night-blindness, central vision is. 
much contracted. Fuchs believes the disease is closely related 
to retinitis pigmentosa, being differentiated from the latter by 
the prominence of the chorioidal atrophy. 

Diseases of the Retinal Vessels. 

Apoplexy of the Retina. — This differs from hemorrhagic ret- 
mitis in that the hemorrhages are found in a retina free from 
other diseased appearances, retinitis in particular. 

With the Ophthalmoscope the extravasations of blood appear 
as red, or almost black, spots of various sizes and shapes. Their 
number and position in the fundus are also variable. They may 
be in any layer of the retina, and sometimes burst into the 
vitreous humor, and sometimes become extravasated between 
the retina and chorioid. 

Vision is interfered with according to the position and extent 
of the hemorrhages. Wherever an apoplexy be situated, the 
function of the retina at that place is suspended. .If it be at 



410 DISEASES OF THE EYE. 

the macula lutea, central vision will be seriously impaired; while 
the scotoma produced by an apoplexy at the periphery of the 
fundus may pass unnoticed by the patient. 

Causes. — Retinal apoplexies are most common in advanced 
life, with atheroma of the blood-vessels, and are then valuable 
as a warning of possibly impending cerebral mischief. Other 
causes are : Hypertrophy of the left ventricle ; suppression or 
irregularity of menstruation or at the climacteric period ; the sud- 
den reduction of tension of the eyeball after iridectomy for 
glaucoma; the gouty diathesis (Hutchinson); progressive per- 
nicious anemia, or anemia from loss of blood (hematemesis, etc.), 
or from exhausting diseases. 

In young people of both sexes, from the fourteenth to the 
twentieth year of age, large retinal apoplexies, which may ex- 
travasate into the vitreous humor, are sometimes seen, and it 
is difficult to assign a cause for them. Some of the subjects are 
weak or anemic, while many of them are in perfect health. 

Prognosis. — The apoplexies are observed, in the course of 
weeks or months, to become paler and smaller, often leaving 
after them chorioidal changes, or grayish spots dependent on 
degeneration of the retina, and in some extreme cases atrophy 
of the whole retina may result. 

Occasionally absorption of the hemorrhages is accompanied 
by complete restoration of vision, but usually the scotomata re- 
main. Recurrences of the hemorrhages are very common. Glau- 
coma comes on as consecutive to retinal apoplexies in some in- 
stances, and is then known as hemorrhagic glaucoma, an incu- 
rable form of the disease (p. 340). 

In other cases the hemorrhage, having invaded the vitreous 
humor, gives rise to dense permanent opacity in it, followed, per- 
haps, by detachment of the retina. 

Treatment. — Active measures are of little use. Cold com- 
presses at first, with a pressure bandage and dry cupping to the 
temple, may be employed. The general state of the patient must 
be attended to, and no violent muscular efforts permitted. 

Embolism of the Central Artery of the Retina. — Sudden or 
very rapid blindness, beginning at the periphery of the field, 
and advancing towards the center, is the only symptom experi- 
enced by the patient. 

Immediately after the attack the Ophthalmoscope shows a 
marked pallor of the papilla, while the artery and its branches 



THE RETINA. 411 

are empty of blood, resembling fine white threads, and the veins 
are diminished in size at the papilla, but increase somewhat to- 
wards the periphery. Pressure on the eyeball produces neither 
pulsation nor change in caliber of the vessels, as it does in a 
sound eye. Usually, on the following day, the central region 
of the retina begins to assume a grayish-white opaque appear- 
ance, consequent on disturbance of nutrition, in the midst of 
which the macula lutea is seen as a purple-red spot. De Schwein- 
itz has seen this cherry-red spot at the macula twenty minutes 
after the embolism took place. The little blood contained in the 
vessels may soon be observed to divide into short columns with 
colorless interspaces, and these short columns move along 
the vessels with a slow jerky motion. Minute hemorrhages 
often occur, most commonly between the macula and the 
papilla. 

The peculiar appearance of the macula lutea is certainly not 
due to hemorrhage. According to Liebreich it is merely a con- 
trast effect, the red color of the chorioid shining through, where 
no nerve-fiber layer is present. Leber suggests that the color 
may be due to the retinal purple. 

The infiltration of the retina passes away in a few weeks, and 
also the peculiar appearance of the macula lutea, while atrophy 
of the retina and papilla usually supervenes. 

Embolism of a branch only of the central artery has been 
observed. In these cases the infiltration and the defect of vision 
are confined to the part of the retina supplied by the embolized 
branch. 

Prognosis. — Vision may improve for a time, but when atrophy 
commences it falls back again, and finally power of perception 
of light is lost. Cases of embolism of a branch are more likely 
to recover. 

Causes. — Endocarditis ; mitral disease ; atheroma of the large 
arteries of the body ; aneurysm of the aorta ; pregnancy ; B right's 
disease. Two cases of chorea with embolism of the central artery 
are recorded.^ But it is said also to occur in healthy persons 
without any discoverable cause. 

Treatment. — Repeated paracentesis of the anterior chamber 
has been tried, and also iridectomy, with the object of reduc- 
ing the tension, and in this way promoting a collateral flow of 
blood, by means of the only ascertained (Leber) communications 
between the retinal and chorioidal vascular systems — namely, at 



412 DISEASES OF THE EYE. 

the entrance of the optic nerve. These attempts have been un- 
successful. 

Several cases have been published in which the circulation, 
v^hich probably was not completely impeded by the embolus, 
was restored and good vision regained, the recovery being 
probably due to the manipulations of the eyeball made in each 
case for the purpose of observing the effect of pressure on 
the vessels. So long as the pressure was maintained, a column 
of blood was being stored up behind the embolus, and, on re- 
moval of the pressure, it rushed forward against the impediment, 
carrying the latter into some more remote vessel or into the 
general vascular system. In fresh cases massage of the eyeball 
suitably applied would, therefore, always be worth the trial. 

Thrombosis of the Retinal Artery. — Blocking of the artery 
may occur spontaneously, from thrombosis due to failure of the 
heart's action and slowing of the arterial flow, the result, in its 
turn, of cardiac disease, spasm of the blood-vessels, disease of the 
walls of the vessels, or alterations in the quantity and amount 
of blood. 

The Ophthalmoscopic Signs are in all respects similar to those 
of embolism. 

The Diagnosis between thrombosis and embolism of the central 
artery can only be made by certain symptoms, which precede 
or accompany the attack in thrombosis, but are wanting in 
embolism. These are : previous attacks of transient blindness 
in the blind eye, a simultaneous attack of blindness in the fellow 
eye, and faintness, giddiness, and headache at the onset of the 
blindness. 

Treatment. — When transient attacks of blindness are com- 
plained of it is important to overhaul the patient's general state, 
and to correct, so far as possible, any condition which might be 
the cause of feeble circulation. When the true attack comes on, 
manipulation of the eyeball applied immediately, or paracentesis 
of the anterior chamber, might prove of use. 

Thrombosis of the Retinal Vein is seen chiefly in old people 
with atheromatous arteries or cardiac troubles. Orbital cellulitis, 
from erysipelas or other causes, may also produce it. 

The Ophthalmoscopic Appearances are: extreme engorgement 
of the retinal veins, with great narrowing of the arteries; the 
whole fundus is thickly studded with dark hemorrhages; the 
optic papilla after a time becomes pale, and undergoes atrophy. 



THE RETINA. 413 

and the hemorrhages, having become absorbed, leave an atrophied 
retina with thready arteries. 

The Prognosis is very bad, sight becoming permanently dam- 
aged or lost, and Treatment can only be directed to the general 
condition. 

Aneurysm of the Central Artery of the Retina occurs either 
as a relatively large dilatation on a main branch of the artery (a 
very rare condition), or as small miliary aneurysms, which may 
indicate the presence of others in the small arteries of the brain. 
Two interesting cases of the latter kind have been recorded, one 
by Story and Benson,* and the other by Perinow ° in men aged 
respectively twenty and forty. In one of these cases there 
were also extensive connective tissue changes in the retina, the 
veins were dilated in places, and only one eye w^as affected. The 
minute aneurysmal dilatations were either globular, and situated 
laterally on the vessels ; or they were fusiform, and involved 
the whole of its lumen. The number of aneurysms in an eye 
varied from three to nine. Neither case was followed to its end ; 
but it is to be presumed that such eyes would run great risk 
of being ultimately lost through intra-ocular hemorrhage. 

A rational Treatment for the condition can hardly be de- 
vised. 

Sclerosis of the Retinal Vessels ( Perivasculitis, or, more 
rarely. Endarteritis) reveals its presence by narrowing of the 
blood column, and by the appearance of white lines along the 
vessels. It usually begins in the large trunks on the papilla, and 
may not extend much beyond the latter, as in some cases of optic 
atrophy; while in other cases (Bright's disease, hereditary syph- 
ilis) it involves the small branches as well, and promotes throm- 
bosis and retinal apoplexies, and may even ultimately lead to 
obliteration of the lumen of the vessels, so that they look like 
white branching streaks. The arteries are more liable to this 
condition than the veins. 

Quinin Amaurosis. — Quinin in large doses, and very oc- 
casionally in small doses, is liable in some individuals to cause 
amblyopia, which may come on almost suddenly, and which 
may amount to absolute blindness, accompanied for some hours or 
days by great deafness. This absolute blindness is rarely more 
than temporary, although it may last for some weeks — indeed, 
there is but one case of permanent quinin amaurosis on record ; 
but in severe cases concentric contraction of the field is apt 



414 DISEASES OF THE EYE. 

to remain permanently, with or without some defect of central 
vision. In the only instance of this more serious result which 
I have seen, the color and light senses, notwithstanding the con- 
tracted field and marked seeming optic atrophy, were normal ; but 
the adaptation of the retina, as shown by considerable night- 
blindness, was defective. 

Major Yarr ® finds that doses of sulphate of quinin of more 
than 20 grains are dangerous to the sight, and that more than 
40 grains should not be given in twenty-four hours. During the 
early stages the pupils are widely dilated, and the cornea and 
conjunctiva are sometimes anesthetic. 

In what may be called the acute stage, the Ophthalmoscopic 
Appearances are sometimes normal, but pallor of the optic papilla, 
with scarcity and smallness of the retinal vessels, is the usual 
condition. Where the case is chronic — the fields remaining con- 
tracted, although central vision has improved — the ophthalmo- 
scope may discover a very pale optic papilla with minimal vessels. 

The retinal ischemia is doubtless the immediate Cause of the 
amblyopia, and is the result of diminished heart's action and 
lowered arterial tension, both of which have been shown to be 
produced by large doses of quinin. Destruction of the ganglion 
cells of the retina towards its periphery has been found, and 
to it may be referred the permanent contraction of the field of 
vision in some cases. 

Treatment. — Cessation of the quinin. Digitalis internally to 
raise the arterial tension, nitro-glycerin, hypodermic injections 
of strychnia, and general tonic treatment. Yarr has found that 
nitrate of amyl causes only temporary improvement of vision. 

Injury of the Retina by Strong Light. 

Blinding of the Retina by Direct Sunlight.— This is espe- 
cially likely to occur on the occasion of solar eclipses, from ob- 
servation with unprotected eye. 

Immediately after the exposure the patients complain of a 
dark or semi-blind spot in the center of the field of vision — a 
positive scotoma, in short, which may even be absolute, and 
which interferes with vision in proportion to the length of the 
exposure. There may also be a central defect for colors, which 
may extend over a larger area. A peculiar oscillation, or ro- 
tary movement, is frequently observed by the patient in the 



THE RETINA. 4^5 

scotoma, and is very persistent. Objects may also seem twisted 
or otherwise distorted (metamorphosia). 

The Ophthahnos^copic Appearances may be normal, but as a 
rule some changes exist, such as an alteration or loss of the 
light reflex at the macula, or a minute pale orange spot near the 
fovea, with, especially in the later stages, some darkening or pig- 
mentation. When the cases are not severe, improvement in 
vision takes place, but complete recovery is not common. Hitherto 
no case in which the vision had been reduced to less than i 
has regained f. 

Treatment. — Hypodermic injections of strychnia, the constant 
galvanic current, and dry cupping on the temple afford the best 
chances for promoting the cure. Rest and dark protection glasses 
are very important. 

Snow-Blindness. — Exposure of the unprotected eyes for a 
length of time to the glare from an extensive surface of snow 
produces, in some persons, a peculiar form of ophthalmia, which 
may be followed by temporary or even permanent amblyopia. 
Although this condition is chiefly an affection of the conjunctiva, 
it is described here in order to compare it with the effects of sun- 
light and electric light. 

Snow-blindness begins with sensations of a foreign body in 
the eye, photophobia, blepharospasm, and lacrimation; later on 
chemosis, with small opacities, or ulcers, of the cornea, comes on. 
The condition passes off in three or four days without leaving 
any permanent ill results, except in rare cases, when there may 
be some secondary hyperemia of the retina. 

Treatment. — The preventative treatment consists in the wear- 
ing of dark smoked glasses when traveling on the snow ; while 
for the ophthalmia cold applications and cocain are recommended, 
to relieve the distressing symptoms. 

Effects of Electric Light on the Eyes. — The degree of in- 
tensity of light required to produce injurious effects on the eye 
is not known; but this much is certain, that no bad results have 
been observed from the ordinary use of the incandescent light. 
Two groups of symptoms are observed from the action of a 
strong electric light on the eyes. 

(a) Electric Ophthalmia. — This has been chiefly seen in those 
employed in electric welding operations, and less frequently in 
electricians who use strong arc-light. The symptoms begin 
shortly after exposure to the light, always within twenty-four 



4i6 DISEASES OF THE EYE. ' 

hours, and are the same as those present in snow-blindness; the 
lids also are swollen, and even erythematous at times. The pu- 
pils are contracted. A slight muco-purulent secretion from the 
conjunctiva appears after the subsidence of the above symptoms. 
Recovery takes place in a few days, with complete restoration 
of vision, except in rare cases. 

(b) Blinding of the Retina. — This is the same affection as 
in blinding of the retina by sunlight. The central scotoma 
may persist after an attack of electric ophthalmia, or may occur 
without it. The injurious action of the electric light on the 
eye has been attributed to the chemical action of the ultra-violet 
rays, to the accompanying heat rays, and to dazzling of the retina. 
Widmark's experiments show that changes can be produced in the 
retina by the electric light, without any heat coagulation. These 
changes consist in edema, with more or less destruction of the 
nervous elements of the retina — namely, the outer layers, in- 
cluding the rods and cones, and the inner layer of nerve fibers. 

Treatment. — The preventive treatment consists in the use of 
colored glasses. Yellow glass has been recommended by Mak- 
lakoff. In the electric welding works in Germany a combina- 
tion of deep blue and red is used, while the Sheffield workers 
prefer several layers of ruby glass. For the rest of the treatment 
see the paragraphs on snow-blindness, and blinding by sunlight. 

It may be as well to mention here that for domestic il- 
luminating purposes electric light possesses many advantages over 
gas, in so far as the use of the eye is concerned. It has a greater il- 
luminating power, produces less heat and no products of com- 
bustion, and hence it does not vitiate the atmosphere, or tend 
to cause conjunctival irritation. The electric light is much 
steadier than gas; and, on account of the smaller quantity of 
red rays which it emits, it forms a nearer approach to sun- 
light than does gas. 

Tumor of the Retina. 

Glioma of the Retina. — This is a malignant growth which is 
found almost exclusively in young children, and may even be 
congenital. It is the only growth which occurs in the retina. 
Owing to the age of the patients, the incipient stages of the dis- 
ease are seldom observed, for they are unattended by pain or in- 
flammation. 

The growth commences as small, white, disseminated swell- 



THE RETINA. 417 

ings in the retina, usually in one or other of the granular layers, 
more rarely in the nerve-fiber layer. The retina is apt to become 
detached at an early period; but there are exceptions to this, 
especially when the disease starts from the nerve-fiber layer. 
In the early stages there is no iritis, cyclitis, or opacity of the 
vitreous humor, and the iris periphery is not retracted — points 
which especially enable us to distinguish it from pseudo-glioma 
(zide Purulent Inflammation of the Vitreous Humor, p. 384). 
Secondary glaucoma finally comes on. The optic nerve may be- 
come involved at an early period ; but sooner or later it invariably 
does so, leading then by extension to glioma of the brain. When 
the tumor has filled the eyeball, it bursts outwards, usually at the 
corneo-sclerotic margin, and then grows more rapidly, and often 
to an immense size, as a fungus hematodes. The orbital tissues 
become involved, and even the bony walls of the orbit ; while 
secondary growths in other organs, more especially in the liver, 
are not rare. 

The diagnosis between glioma of the retina and tubercle of the 
chorioid (p. 294), when the latter occurs in young children, is 
sometimes difficult or impossible ; but, in view of treatment, it is 
not of great importance, as in either case the eye must be 
enucleated. 

Treatment. — The only hope of saving the patient's life lies in 
enucleation at an early stage, or before the optic nerve becomes 
diseased. It is important in removing the eyeball to divide the 
nerve as far back as possible ; and, if the orbital tissues be al- 
ready diseased, to remove all suspicious portions of them. Sev- 
eral cases in which there was no return of the growth have been 
observed. 

Parasitic Disease. 

Cysticercus under the Retina. — The cysticercus of the tsenia 
solium in the eye is extremely rare in these countries, but is not 
so very rare in Germany. Its most frequent seat is between the 
retina and chorioid, where it is recognized with the ophthalmo- 
scope as a sharply defined bluish-white body, with bright orange 
margin. At one point of the cyst there is a very bright spot, 
which corresponds with the head of the entozoon. Wave-like 
motions along the contour of the cyst should be looked for to 
confirm the diagnosis. The cysticercus may move from its origi- 

35 



4i8 DISEASES OF THE EYE. 

nal position, and in so doing cause considerable detachment of 
the retina. DeUcate veil-Hke opacities are apt to form in the 
vitreous humor, and are almost characteristic of the presence of 
cysticercus. 

The entozoon may become encapsulated behind the retina ; or it 
may burst into the vitreous humor (p. 396) ; and finally chronic 
iridocyclitis, with total loss of sight and phthisis, is apt to 
come on. 

Treatment. — We are not acquainted with any anthelmintic 
which will act upon the entozoon in the eye. Removal of the 
cyst by operation is the only means by which the eye can be saved ; 
and this measure can only be resorted to when the position of the 
cysticercus is unfavorable for it — e. g., when it is close to the 
equator of the eyeball. By a well-placed puncture through the 
sclerotic and chorioid the entozoon may then be evacuated. 

Detachment of the Retina. 

This condition consists in a separation of the retina from the 
chorioid, the intervening space being occupied by a clear serous 
fluid. It is not usual to employ the term when it is a solid neo- 
plasm only that lies between retina and chorioid. 

If the media be clear and the detached portion extensive, the 
diagnosis is not difficult. 

The Ophthalmoscope shows a grayish reflex from a position in 
front of the fundus oculi, and to the surface from which the re- 
flex is obtained a wave-like motion is imparted when the eyeball 
is moved. Over this grayish surface the retinal vessels run, and 
they serve to distinguish a detached retina from any other diseased 
condition with a somewhat similar appearance. They seem black, 
not red, in consequence of absorption of the transmitted light, and 
are hidden from view here and there in the folds of the detached 
retina. In many cases a rent in the detached retina, through 
which the chorioid can be discerned, will be discovered. 

The detachment may commence in any portion of the fundus, 
but most commonly above ; yet, owing to gravitation of the fluid, 
it ultimately settles in the lower half of the fundus, and hence this 
is the most common place to find it, the part first detached having 
become replaced. The diagnosis is more difficult if there be but 
little fluid behind the retina, or if there be opacities in the vitreous 
humor. 



THE RETINA. 419 

Vision is affected according to the position and extent of the 
detachment. Central vision may be quite normal if the macula 
lutea and its immediate neighborhood are intact. The patients 
complain of seeing objects distorted, of a black veil which seems 
to hang over the sight, and sometimes of black floating spots be- 
fore the eye, due to opacities in the vitreous humor. These symp- 
toms often come on suddenly in an eye which has hitherto had 
good sight. 

The field of vision, on examination, will show a defect corre- 
sponding to the position of the detachment. If, for example, it 
be below, the defect will be in the upper part of the field. If the 
detachment be fresh, the retina not having yet undergone sec- 
ondary changes, and if the quantity of subretinal fluid be not 
great, the defect in the field may only amount to an indistinctness 
of vision ; while later on, when infiltration and connective tissue 
degeneration of the detached part come about, fingers may not be 
counted at the same place. The phosphenes * of the detached 
portion are wanting. 

Should the detachment become complete, little more than mere 
power of perception of light may be present. Total detachment 
is followed by cataract, and often by iritis, cyclitis, and phthisis 
bulbi. The detachment may remain stationary, and not extend to 
the whole fundus, or the retina may return to its normal position ; 
but such a happy event is most rare. 

Causes. — Myopic eyes — which we know are so frequently 
affected with chorioiditis and disease of the vitreous humor — are 
those most subject to detachment of the retina; but idiopathic de- 
tachment occurs also in eyes which are apparently healthy. 
Blows upon the eye may produce detachment, the retro-retinal 
fluid being serous or bloody. Some punctured wounds of the 
sclerotic, also, in the course of healing, by dragging on the retina, 
give rise to it. Chorioidal tumors, especially those situated in 
the posterior segment of the fundus, usually cause detachment in 

* Phosphene is the subjective sensation of light experienced when the 
eyeball is pressed upon. For clinical purposes it is best tested by gentle 
pressure with a blunt point (head of a bodkin or large-sized probe) ap- 
plied to the eyeball through the eyelid. The phosphene of any region 
is tested by applying pressure to that part of the globe. Thus, if in a 
healthy eye the individual look down, and pressure be applied to the upper 
part of the globe through the eyelid, the phosphene will be seen appearing 
below ; but if there be a detachment of the retina at the place pressed on, 
no phosphene is seen, 



420 DISEASES OF THE EYE. 

an early stage of their growth, and the compHcation renders their 
diagnosis more difficult (p. 292). 

Leber ^ observed that in non-traumatic detachment a perfora- 
tion or rent in the detached portion is very frequently to be seen 
with the ophthalmoscope, and holds that it is probably always pres- 
ent, although sometimes, from being hidden behind a fold of the 
retina, it cannot be found. He was led from this, and from his 
pathological investigations and experiments upon animals, to 
think that the detachment was due to shrinking of a diseased 
vitreous, which first became slightly separated from the retina, 
and that then — at some place where the retina and hyaloid had 
become adherent from the inflammatory process — a rent was pro- 
duced in the retina by the shrinking process in the vitreous. He 
concluded that through this rent the fluid, which is always present 
behind the vitreous in cases of detachment of that body, makes 
its way behind the retina, and separates the latter from the cho- 
rioid. Nordenson's pathological researches ^ went to corroborate 
this. He ascertained, too, that disease of the ciliary body and 
chorioid is the primary cause, although we may not be always able 
to detect it with the ophthalmoscope, and that the pathological 
change in the vitreous humor consists in an alteration in its con- 
nective tissue elements, resulting in the deleterious shrinking. 

Raehlmann,^ however, from the results of experiments, and also 
from clinical observation, concludes that detachment of the retina 
is due to exudation from the chorioidal vessels of a fluid which is 
more albuminous than the fluid in the vitreous humor. Hence, 
he thinks, diffusion takes place through the retina, and a greater 
quantity of the less albuminous vitreous fluid passes through 
the retina, thus producing and increasing the detachment. Rup- 
ture of the retina is not, in his view, a necessary factor in the 
causation, but it may occur if the tension behind the retina be 
higher than that in front of it. 

Treatment. — Evacuation of the subretinal fluid by puncture 
of the sclerotic was proposed by Sichel, and cultivated by de 
Wecker. The instrument resembled a broad needle, with a sharp 
point and two, blunt edges, which is entered through the sclerotic 
and chorioid at a place corresponding to the position of the de- 
tachment, but not so deeply as to reach the retina, lest thereby 
it be further displaced. The instrument is then given a quarter 
of a rotation, to make the wound gape, so as to admit of the flow- 
ing off of the fluid. If possible a position near the equator of the 



THE RETINA. 421 

globe, and between two recti muscles, should be selected for the 
operation. Moreover, the incision should lie parallel to the direc- 
tion of the orbital muscles, so that the chorioidal vessels may be 
injured as little as possible. A firm bandage is applied, and the 
patient kept in bed for eight or ten days. 

The dorsal position in bed, with a pressure bandage on the 
eye, and diaphoretics internally, the treatment being continued 
for from four to six weeks, brings about reposition of the detach- 
ment in some cases. The method, if properly carried out, is try- 
ing to the patient, but it is only rarely of use. 

The cures which have been accomplished by these means prob- 
ably depend upon the retina again coming in contact with the 
chorioid, and, owing to some slight inflammatory process, adher- 
ing to it. For the most part the cure is but temporary, and in 
such cases we may suppose that no adhesion sprang up, but that 
the temporary cure was due to a return of the subretinal fluid, 
through the hole in the retina, to its original position between 
the retina and vitreous. Soon, however, it makes its way back 
again through the opening, and the detachment recurs. 

To promote adhesion between retina and chorioid, Dor ^^ touches 
the sclerotic corresponding to the detachment lightly with a small 
cautery, injects rather strong (10 per cent.) solutions of common 
salt under the conjunctiva, and keeps the patient in bed. He re- 
ports some cures by this method. 

Schoeler ^^ injects tincture of iodin into the vitreous humor 
in front of the detached retina, in order to press it back to the 
chorioid, and to produce a plastic chorioido-retinitis, which may 
unite the two coats. He has reported several good results by this 
method, but some who have tried it have experienced violent 
inflammatory reaction in the eyes operated on, with disastrous 
consequences, and the treatment is discredited, 

Deutschmann ^^ has proposed the following method of treat- 
ment. Adopting the theory of retraction, he passed a double- 
edged narrow knife through the sclerotic, chorioid, and retina, 
into the vitreous humor, dividing cords and liberating fluid from 
before and behind the retina. The vitreous of a rabbit's eye di- 
luted with a few drops of a 7 to 100 solution of chlorid of sodium 
was triturated. Of this a few drops were injected with a hypo- 
dermic syringe into the vitreous cavity of the eye. By this pro- 
cedure it was intended to press the retina permanently against the 
chorioid, until the ensuing uveitis had established agglutination 



422 DISEASES OF THE EYE. 

of the retina to the chorioid. In a good many cases where this 
operation has been tried it has done harm rather than good. 

Grossmann ^^ tried aspiration of the siibretinal fluid, with 
simultaneous increase of the pressure in the vitreous humor, by 
injections into the latter of four or five drops of an indifferent 
fluid, namely, a 0.75 per cent, tepid solution of common salt. 
The results obtained were encouraging in the three cases re- 
ported. 

Galezowski ^* simply aspirates the subretinal fluid. 

Electrolysis has been tried. 

Pilocarpin used hypodermically has been praised by some as a 
mode of treatment, as, also, salicylate of sodium internally. 

Formerly an active mercurial treatment used to be employed, 
with the object of obtaining absorption of the fluid. 

The Prognosis of every case of detached retina is bad, spon- 
taneous cure being extremely rare, and the cures by any one or by 
any combination of the above methods of treatment being few and 
far between ; and when the retina does return to its place, there is 
the danger of a recurrence of the detachment. Moreover, both 
eyes are often affected, one after the other. The most favorable 
cases are those due to chorioiditis, the most unfavorable those due 
to posterior staphyloma. 

Traumatic Affections of the Retina. 

In addition to detachment and rupture of the retina, the under- 
mentioned conditions occur as the results of injuries. 

Traumatic Anesthesia of the Retina.— A blow on the eye 
from a fist, cork from a bottle, etc., is liable to produce consider- 
able amblyopia, with concentric contraction of the field, which may 
continue for a long time, while the Ophthalmoscopic Appearances 
are normal. Ultimately these cases usually recover, an event 
which may be decidedly promoted by the use of strychnin hypo- 
dermically; but very defective sight sometimes remains perma- 
nently. 

Commotio Retinae, or Traumatic Edema of the Retina, 
is the result of a blow upon the eye. Immediately after the blow 
there is marked episcleral injection, and the pupil can be dilated but 
slowly with atropin. Within a few hours after the accident the 
Ophthalmoscope reveals a white cloudiness of a portion of the 
retina, usually in the neighborhood of the optic papilla and 



THE RETINA. 423 

macula, but sometimes more eccentrically; and sometimes there 
are two opaque patches. The opacity increases in intensity, and 
spreads somewhat. The retinal vessels remain normal ; there may 
be some small hemorrhages, and sometimes the papilla is redder 
than normal. These appearances completely disappear in the 
course of a few days. Vision is only slightly affected, and re- 
covers according as the retinal changes pass off. 

References. 

*"Von Graefe's Archiv," xxxix. 3. p. 227. 
' " Arch. f. Ophthal.," xxvii. p. 484. 

'"Roy. Lond. Hosp. Rep./' 1875. "Ophthalmic Review," v. p. 1. 
* " Trans. Ophthal. Soc, U. K.," vol. iii, p. 108. 
^ " Centralbl. f. Augenheilkunde," 1883, p. 392. 
"^ " Journ. Tropical Medicine," November, 1898. 
' " Bericht d. Ophthal. Gesellsch." Heidelberg, 1882, p. 18. 
^ " Die Netzhautablosung." Wiesbaden, 1887. 
'' " Archiv fiir Ophthal.," xxvii. part i. p. i. 

^^ " Bulletins de la Societe francaise d'Ophtalmologie," 1895, 1896. 
" " Zur operativen Behandlung und Heilung der Netzhautablosung." 
Berlin, 1889. 
^' " Beitrage zur Augenheilkunde," xx. p. i. 
" " Ophthalmic Review," 1883, p. 89. 
" " Recueil d'Ophtalmologie," Mars, 1888. 



CHAPTER XVI. 
DISEASES OF THE OPTIC NERVE. 

Optic Neuritis. — The Ophthalmoscopic App^earances of in- 
flammation of the optic nerve vary a good deal with the intensity 
of the process. Common to every case is hyperemia and swelHng 
of the papilla, with haziness (so-called " woolliness ") of its mar- 
gins, and increase in the size of the central vein, while the central 
artery remains of normal dimensions, or is contracted. The swel- 
ling and haziness extend but a short distance into the surrounding 
retina, and the distention of the vein is also not continued to the 
periphery of the fundus. In slight cases these appearances may 
barely exceed the normal. 

In extreme instances the papilla is swollen to a great size, and 
may even assume quite a dome shape, while the veins are enor- 
mously distended and tortuous, and the arteries are contracted so 
as to be barely visible. Grayish striae extend from the papilla into 
the surrounding retina, some flame-shaped hemorrhages are pres- 
ent on or near the papilla, and, occasionally, white spots in the 
retina, and a stellate arrangement of small white dots about the 
macula lutea produce an appearance which cannot be distinguished 
from albuminuric retinitis. This extreme form is still sometimes 
termed Congestion Papilla, or Choked Disc (Stcimngspapille), al- 
though the theory which originally suggested the term has been 
abandoned. Papillitis (Inflammation of the Optic Papilla) is a 
better term, expressing, as it does, more truly the pathological 
condition. 

The Vision, even in cases where the ophthalmoscopic signs 
are highly developed, is frequently but little below the normal ; 
while, again, in other, and possibly less well-marked cases, 
in so far as the appearances are concerned, it may be reduced to 
perception of light, or even that may be wanting. When due to 
cerebral tumor, the neuritis appears as a rule before the vision be- 
comes affected. These remarkable differences in the degree of 
blindness depend, probably, on the extent to which the nervous ele- 

424 



THE OPTIC NERVE. 425 

ments of the inflamed part are pressed on or altered, and this can- 
not be gauged by the ophthalmoscopic appearances. 

Sometimes the field of vision is normal, while again it is con- 
centrically or irregularly contracted, or it may be hemianopic. 

An attack of temporary loss of sight is a very common symp- 
tom in cerebral tumors ; it may occur several times a day, and may 
last from a few minutes to half an hour. 

Pathologically, the changes in the papilla consist in venous hy- 
peremia, edema, hypertrophy of the nerve fibers, infiltration of 
lymph cells, and development of connective tissue. Inflammatory 
changes, although less pronounced, are also present in the trunk 
of the nerve and its sheaths. 

Causes. — Inflammation of the optic nerve is most commonly 
found in connection with coarse encephalic disease. A Cerebral 
Tumor (including syphiloma, tubercle, and abscess) in particular 
is the most common cause, and is, moreover, usually present when 
the papillitis is of an intense kind (choked disc). The neuritis, 
except in very rare instances, is bilateral, and it is one of the gen- 
eral symptoms of cerebral tumor. Hemianopsia may coexist as a 
localizing symptom, if the visual center or fibers on one side be 
involved. Even a small tumor situated anywhere in the brain is 
capable of producing optic neuritis, although unattended by men- 
ingitis. Cerebral cysts do not often cause it. 

Tubercular Meningitis is the next most common cause. Non- 
tubercular meningitis occasionally gives rise to optic neuritis, and 
sometimes, also, cerebrospinal meningitis does so. 

The Connection between Optic Neuritis and Intracranial Dis- 
eases has given rise to much discussion. In cases of tumor, as 
well as of tubercular meningitis, a considerable exudation of fluid 
usually takes place into the cavity of the third ventricle. This, 
along with the new growth, or alone in cases of meningitis, in- 
creases the pressure within the cranial cavity. By reason of this 
increased intracranial pressure, the subarachnoid fluid is believed 
to be driven into the subvaginal lymph space of the optic nerve, 
and to produce there that dropsy of the sheath which is found in 
nearly all these cases on careful postmortem examination. 

Leber holds ^ that this fluid probably contains a phlogogenic 
substance. It seems probable that the reason why some small 
cerebral tumors may cause optic neuritis, while some large ones 
do not, is to be sought in the fact that the former may happen to be 
rapidly growing tumors, and accompanied by much ventricular 
36 



426 DISEASES OF THE EYE. 

dropsy, while the larger tumors may be slow in growth, and at- 
tended by but little dropsy of the ventricles. Moreover, the fluid 
driven into the subvaginal sheath of the optic nerve may not be 
equally rich in phlogogenic substance in the case of every 
tumor. 

The inflammation, although most intense at the papilla, near 
which the fluid is collected in greatest quantity in the cul-de-sac 
formed by the termination of the intervaginal spaces, is not con- 
fined to that place, as was believed, but extends up the trunk of the 
nerve, as microscopic examination reveals. 

Many observers state that in a large number of cases cerebritis, 
recognizable only with the microscope, is present, and that an ex- 
tension of this process down the optic nerve takes place. They 
have ascertained that the whole trunk of the nerve is involved in 
the inflammation, and they seem to regard the dropsy of the sheath 
as of little or no importance in the causation of the optic neuritis. 

Again, others maintain that edema, but not inflammation of 
the optic trunk is conducted from the brain. 

Other causes for Optic Neuritis are: 

Hydrocephalus. — Here the pathogenesis is probably the same 
as in the foregoing ; but the occurrence of optic neuritis is, on the 
whole, not very common in this connection. 

Tumors of the Orbit. — The path by which these growths bring 
about papillitis is still unknown. 

Inflammatory Processes in the Orbit, such as caries, inflamma- 
tion of the retro-orbital areolar tissue, erysipelas of the head and 
face extending to the orbital tissues, and periostitis. The pres- 
ence of the latter may often be recognized by pain on motion of 
the eyeball, pain in the eye and forehead, and especially by pain 
on pressure of the globe backwards, and is frequently of rheumatic 
origin. Often in these cases one eye only is aflfected ; and, although 
the Ophthalmoscopic Appearamces are sometimes very slight, yet 
vision may be quite lost in a few hours or days, atrophy of the 
nerve then rapidly setting in. 

Very many of the cases, however, do not go on to atrophy, but 
end in recovery of useful vision. 

Exposure to Cold, especially if the skin be heated and per- 
spiring. 

Suppression of the Menstruation. — If during the menstrual 
period the flow be arrested by exposure to cold, wet feet, etc., acute 
optic neuritis with rapid blindness may come on. Spontaneous 



THE OPTIC NERVE. 427 

amenorrhea, or even irregularity of menstruation, and the cH- 
macteric period are hable to have a similar, but more chronic, re- 
sult. Nothing is known with regard to the connection between 
the uterine and ocular disorder. In these cases the Ophthalmo- 
scopic Appearances, as well as the blindness, are apt to be ex- 
treme. Treatment here should be directed chiefly to restoring, 
when possible, the normal uterine functions. Hot foot-baths 
and Heurteloup's leech to the temples are of use. 

Chlorosis. — Here optic neuritis often is present, due to the dis- 
ordered state of the blood, and usually yields under the influence 
of iron. 

Syphilis. — The trunk of one or both optic nerves may be 
the seat of specific inflammation in connection either with con- 
genital or with acquired syphilis, but this primary specific optic 
neuritis is a relatively rare disease. In cases of acquired syphilis 
it makes its appearance in from six months to two years after the 
inoculation. 

The Ophthalmoscopic Appearances may be normal ( retrobulbar 
neuritis), or may present any grade of neuritis, even to the most 
pronounced papillitis. In the latter case it would not be possible 
to say whether the papillitis is a primary one, or is due to a 
syphilitic gumma within the cranium. The inflammation often 
extends as far up as the chiasma. 

The Treatment in these cases of specific papillitis must be active 
mercurialization. By this treatment, even if perception of light be 
lost for a period of not more than eight to fourteen days, hopes 
may be entertained of its complete or partial recovery. 

Cases of double optic neuritis of syphilitic origin have been 
observed, in which complete recovery took place, the papilla re- 
turning to its normal condition. But, as a rule, some optic at- 
rophy, at the least, with slight concentric contraction of the field, 
results. The prognosis is all the better the sooner the optic neu- 
ritis follows upon the primary syphilitic affection. 

Rheumatism. — There is no doubt whatever but that the rheu- 
matic diathesis is occasionally the cause of optic neuritis, although 
the fact is not unreservedly accepted by every author. Other 
manifestations of rheumatism are sometimes well marked, but 
may be slight — e. g., in a case which I saw, neuralgia of the face 
and head in damp weather, and even with a shower of rain, was 
the only other sign of rheumatism. One or both optic nerves 
may be attacked. 



428 DISEASES OF THE EYE. 

The Ophthalmoscopic Appearances often amount to extreme 
papillitis, but in many cases fall short of this. 

If the case come early under suitable treatment the Prognosis 
is fairly favorable; but when the inflammation is of some stand- 
ing, consecutive optic atrophy must be feared. 

The Treatment consists of full doses of salicin, salicylate of 
sodium, iodid of potassium or of sodium, Turkish baths, and other 
recognized antirheumatic measures. 

Lead-Poisoning. — In some cases of lead-poisoning optic neu- 
ritis, not to be distinguished from that of primary cerebral affec- 
tions, is found. Sometimes the Ophthalmoscopic Appearances 
are very slight, and, again, quite pronounced, the changes extend- 
ing into the retina. They sometimes simulate the retinitis of 
Bright's disease ; and in such cases renal disease is likely to have 
much to do with the causation of the retinitis. Indeed, there are 
those who, with good opportunities for forming a correct opinion, 
deny the existence of a specific lead neuritis, and hold that the 
neuritic affection in all such cases is to be referred to albuminuria, 
to effusion into the ventricles of the brain and subrachnoid space, 
or to accompanying suppression of menstruation. Occasionally 
optic atrophy is the first ophthalmoscopic appearance seen ; but it 
is probably consecutive to retrobulbar neuritis, as shown by white 
striae (perivascularitis) along the vessels. 

The Vision is often much affected, and it is stated that sudden 
complete blindness in connection with an intercurrent attack of 
lead colic may appear and pass off again. Consecutive atrophy 
is liable to come on, and then vision may be seriously and per- 
manently damaged. 

The Diagnosis depends entirely on the presence of the other 
well-known symptoms of lead-poisoning, the Ophthalmoscopic 
Appearances presenting nothing pathognomonic. 

The Treatment is that for general lead-poisoning, or for the 
immediate cause of the neuritis. 

In Peripheral Neuritis optic neuritis is occasionally found. 

Multiple Sclerosis. — In these cases the inflammation is very 
ephemeral, and rapidly gives place to atrophy. Uhthoif states 
that it occurs in about 13 per cent, of the cases of this 
disease. 

Tabes Dorsalis. — A few cases of this disease are published in 
which optic neuritis was present. It is probable that the latter de- 
pended on coexistent syphilitic cerebral disease, rather than on 



THE OPTIC NERVE. 429 

the spinal disorder as such. In Acute Myehtis inflammation of 
the optic nerve is sometimes seen, so that optic neuritis with 
paralytic phenomena does not exclusively indicate cerebral 
disease. 

Hereditary and Congenital Predisposition. — It has been ob- 
served that optic neuritis, without immediate cause, may attack 
several members of a family, and that the tendency to it may 
extend over several generations. It makes its appearance about 
puberty or a little later in males, and about the climacteric in 
females, but is much rarer in the latter. The patients may be per- 
fectly healthy in all other respects, but many of them suffer from 
other affections of the nervous system. Both eyes are affected, 
the defect of vision being a central amblyopia (central scotoma), 
from which recovery is rare; but yet, although the Ophthalmo- 
scopic Appearances gradually become those of atrophy, the periph- 
eral portions of the field retain their functions. Optic neuritis 
in this form was first thoroughly described by Leber,^ and is gen- 
erally known as Leber's disease. 

As to the treatment of these cases, due to hereditary and con- 
genital predisposition, Mooren has employed a seton in the back of 
the neck in the early periods, and, later on, nitrate of silver in- 
ternally. Leber has found benefit from a mild course of mercurial 
inunction. 

Optic Neuritis also occurs occasionally in fevers; it has been 
observed in Measles, Scarlatina, Typhoid, and Malaria. It may 
follow Influenza, causing contraction of the field of vision or 
central scotoma which usually disappear, but, on the other hand, 
it may lead to optic atrophy. 

The two following diseases — Toxic Central Amblyopia, or 
Central Scotoma and Optic Neuritis with Persistent Dropping 
from the Nostril — must be treated of separately, owing to the well- 
defined etiology of the one and the peculiar symptoms of the 
other. 

Toxic Central Amblyopia, or Central Scotoma. — 

Symptoms. — The affection of vision often comes on rather 
rapidly. The patient may complain of a glimmering mist which 
covers all objects, especially in a bright light, and the acuteness of 
vision is reduced. The patient generally states he can see better 
in the dusk than in bright light. At the commencement there is 
no defect in the field of vision, but simply a o^eneral dimness of 
vision. At a somewhat later stage examination of the field dis- 



430 DISEASES OF THE EYE. 

covers no defect for a white object; yet, if a small pale green 
object be employed, it will generally be ascertained that, at a 
region close to the point of fixation, the color is not recognized, but 
seems gray or white; pink may seem blue, and red may appear 
brown or black; while in other parts of the field the colors are 
recognized up to their normal boundaries. This is a central color- 
scotoma. As the disease advances a white object will be but in- 
distinctly seen in the scotoma; and in some rare cases all power 
of perception within its area may be lost, even the flame of a candle 
not being recognized. Hence the name Central Amblyopia. The 
scotoma is usually oval in shape, its long axis horizontal, and 
extends from the fixation point towards the blind-spot of Mariotte 
(paracentric scotoma) ; but occasionally it is of much larger di- 
mensions, and sometimes surrounds the fixation point (pericentric 
scotoma) . 

Even when the scotoma is very pronounced it remains nega- 
tive — i. e., it is not observed by the patient as a dark spot in the 
field, as is a scotoma due to disease in the outer retinal layers. The 
affection is almost always binocular, and as a rule there is but little 
difference between the vision of the two eyes. 

The Prognosis of the disease is slow, occupying weeks or 
months. Restoration of normal vision usually takes place if the 
defect of vision, although of extreme degree, be not of old stand- 
ing. In the latter case, while recovery of central vision cannot 
be expected, the functions in the periphery of the field are usually 
maintained; and, consequently, these people, although incapaci- 
tated from reading, writing, and other fine work, do not lose their 
power of guiding themselves. 

Causes. — With but few exceptions the subjects of this disease 
are men, probably because their habits and modes of life expose 
them, more than women, to the influences which produce it. 
These are: Exposure to cold and wet; cold blasts on the body, 
especially the heated face (Samelsohn) ; but the most common 
cause is excess in the use of alcohol, or of tobacco (toxic am- 
blyopia), or of both. I have observed that the kind of alcoholic 
indulgence most likely to develop the disease is the frequent drink- 
ing of small doses of the stimulant. The individual who often 
gets thoroughly intoxicated, and between times drinks but little, 
is less liable to central amblyopia than he who^ although never 
incapable of transacting his business, takes many half-glasses of 
whisky or brandy during the day. Dyspepsia and loss of appe- 



THE OPTIC NERVE. 431 

tite are constantly present in these cases. Other signs of chronic 
alcoholism need not be present, but one often sees trembling of 
the hand and head, sleeplessness, and even delirium tremens. The 
kind of tobacco most likely, when used in excess, to give rise to 
central amblyopia is shag or twist. Other kinds of pipe-tobacco 
and cigars may cause it, but I have not known of a case due to 
cigarette-smoking. 

Excess in alcohol is usually combined with excessive smok- 
ing, but cases of pure alcohol-amblyopia certainly do occur — al- 
though some English authors deny it — as well as pure tobacco- 
amblyopia. The most common age for tobacco-amblyopia is from 
thirty-five to fifty — a time of life when men do well to give up, or 
to very much reduce, their use of tobacco, as well as of 
alcohol. 

Central amblyopia has also been observed in diabetes, in poi- 
soning from bisulphid of carbon,^ so largely used in the manu- 
facture of india rubber, from dinitro-benzol,* used for explosives, 
and in iodoform poisoning.^ 

The Ophthalmoscopic Appearances in the beginning are either 
quite normal or there is slight hyperemia of the papilla and retinal 
vessels; or, in addition, there may be slight indistinctness of the 
margins of the papilla, and sometimes white striae along the ves- 
sels, especially before they leave the papilla. All the primary ap- 
pearances, if any be present, soon pass away, and give place to a 
grayish whiteness of the temporal side of the papilla, while the 
nasal portion remains of normal appearance, as do also the ves- 
sels. At a very advanced stage, in some cases, the whole papilla 
presents the appearance of white atrophy. 

The Pathological Changes observed by Samelsohn, Nettleship, 
and Walter Edmunds, and UhthoiT, in the optic nerve, consist 
of an interstitial nephritis at its axis, commencing so high up as the 
optic foramen, and leading to proliferation of connective tissue 
and to secondary descending atrophy of a certain bundle of nerve 
fibers. These are the fibers which supply the region of the 
macula lutea. The changes are analogous to those which take 
place in the liver and brain as the result of chronic alco- 
holism. 

Treatment consists, above all, in total abstinence from the poison 
in question. The patients are generally ready to promise this, but 
they often do not act up to their intentions. When they do so, 
improvement rapidly takes place in most cases which are not too 



432 DISEASES OF THE EYE. 

far gone, without any other treatment ; but the cure may be pro- 
moted by the use of iodid of potassium in large doses, Heurte- 
loup's artificial leech or dry cupping to the temples, hot foot-baths, 
and Turkish baths. Strychnin hypodermically (1-30 grain daily) 
in the temple is often of use, and phosphorus and strychnin may 
be given internally. Whatever remedy be used internally, care 
should be taken that it does not produce or increase dyspepsia ; 
and it may be necessary to restrict the internal medicine for a 
time, or altogether, to a stomach tonic. Sleeplessness should be 
combated with sulphonal or bromid of potassium. Treatment may 
have to be continued for some weeks, before a cure may be 
noted. 

Retrobulbar Neuritis. — This is by no means a very common 
disease. It is ushered in by rapid loss of sight in one eye, some- 
times in both, or they may be attacked with a considerable in- 
terval between. Examination of the field of vision discovers a 
central scotoma, which is often absolute. At the commencement, 
pain in the orbit is complained of, the motions of the eye are 
somewhat painful, and there is pain on moderate pressure of 
the globe backwards into the orbit. Often at first there are no 
ophthalmoscopic changes, but after a time marked optic neuritis 
shows itself, and this may pass into atrophy, or atrophy may ap- 
pear without any previous neuritis which can be discerned. It 
is rare for complete and absolute amaurosis to result, although 
the optic disc remains white. In most of the cases the central 
scotoma disappears, and almost normal vision is restored ; but in 
some a more or less well-marked central scotoma, with defective 
sight, remains. The prognosis is all the better if the case comes 
under treatment very early. 

Exposure to severe blasts of cold wind on the head, rheumatism, 
and influenza are the most common causes. 

Treatment. — Iodid of potassium in large doses, mercury, and 
salicylate of soda. 

Optic Neuritis associated with Persistent Dropping of 
Watery Fluid from the Nostril. 

Twenty-one cases of this remarkable disorder, including a 
case of his own, have been collected by St. Clair Thomson ^ in a 
valuable monograph, and others have since then been reported. 
In eight of these cases the eyesight was affected, there being optic 
neuritis or secondary atrophy. The patients suffered from a per- 
sistent watery discharge from the nose (usually the left nostril), 



THE OPTIC NERVE. 433 

with more or less severe cerebral symptoms : violent headache, 
epileptic attacks, vomiting, stupidity, sleepiness, unconsciousness, 
delirium, weakness of the lower extremities, and a high degree of 
amblyopia, or even blindness, of both eyes, due to papillitis fol- 
lowed by atrophy. The severity of the head symptoms varies 
very much in different cases. Headache is the most constant of 
these symptoms, but even it was absent in one case. In Leber's 
case, moreover, there was loss of smell, and in Nettleship's case 
palpitation of the heart and prominence of the eyes. The fluid 
which runs from the nostril is identical in its analysis with that 
of the cerebrospinal fluid. If it occasionally ceases to flow, the 
cerebral symptoms are brought on, or increased in violence. 
Leber's case was one of internal hydrocephalus, and the other cases 
were probably of similar nature. He regards the fluid as com- 
ing from the third ventricle, through a small opening in the 
ethmoid bone; or the fluid possibly passed from the subdural 
space along the lymph spaces, which surround the olfactory 
nerves. 

The affection commences usually in early adult life, and 
no rational treatment for it has been suggested. The flow may 
cease spontaneously for periods varying from a few hours to 
several months. In some cases it ceased altogether, or at least 
had not recurred after an intermission of five or even fourteen 
years. Most of the cases have been lost sight of, but some are 
recorded as having died of meningitis. 

Atrophy of the Optic Nerve. — This disease may be secondary 
to some other optic nerve or retinal affection, or it may be a 
primary disease. The Vision is seriously affected, and complete 
blindness is the usual result. With the Ophthalmoscope the op- 
tic papilla is seen to have lost its delicate pink color, and to have 
become white or grayish, while it is often cupped, and the vessels 
are apt to be diminished in caliber. 

Secondary Atrophy of the Optic Nerve may result : 

I. From Optic Neuritis. — The ophthalmoscopic appearances 
consist in a white or grayish-white color of the papilla, with very 
diminished retinal vessels ; and along both sides of the vessels, far 
into the retina, are seen white lines, which sometimes even ob- 
scure the vessels, and which are due to hypertrophy of their coats. 
The diminution in caliber of the vessel is a sign of neuritic at- 
rophy, but is not always present, and is moreover found with 
other forms of atrophy. Other signs of this form, also not con- 



434 DISEASES OF THE EYE. 

stant, are: a certain opacity of the papilla, and that the lamina 
cribrosa is not generally visible, owing to development of con- 
nective tissue at the papilla. It is evidently not always possible 
to recognize any given case as of neuritic origin. 

Symptoms. — The acuteness of vision is lowered, and as a rule 
the field of vision becomes contracted, usually more at the nasal 
than at the temporal side. Subsequently the temporal side of the 
field becomes contracted, and finally a small eccentric portion of 
the field to the temporal side may be all that remains, or even this 
may disappear, and absolute amaurosis result. The color-vision 
is always much affected. The light-sense is affected, so that there 
is diminished sensibility for differences of illumination; while, in 
chorioido-retinal diseases, there is defect in the quantitative per- 
ception of light, the minimum quantity being larger than normal. 

2. From. Pressure. — This may be brought about by a tumor 
anywhere in the course of the nerve, by inflammatory exudations, 
by a splinter of bone in cases of fracture of the skull, and, also, 
by pressure upon the chiasma by the floor of -the distended third 
ventricle in cases of internal hydrocephalus. 

3. From Embolism of the Central Artery of the Retina. — In 
these cases the contraction of the vessels is usually extreme. 

4. From Syphilitic Retinitis, Retinitis Pigmentosa, and Cho- 
rioido-retinitis. — The vessels here are much attenuated, and the 
altered color of the optic disc is a dull yellow rather than white or 
gray. 

Primary Optic Atrophy is often found associated with: 
Disease of the Spinal Cord (Spinal Amaurosis) , especially loco- 
motor ataxy. Optic atrophy is often an early symptom in the 
latter disease ; but, again, it may not come on until the affection of 
the gait is well pronounced, while in other cases it is never pres- 
ent at all. It is a remarkable and important fact, first pointed out 
by Benedikt of Vienna, that there is an antagonism between 
atrophy of the optic disc and the other symptoms of tabes dorsalis. 
It is rare for a tabetic patient, in whom optic atrophy comes on 
in an early st^ge of his disease, to become ataxic ; and, frequently, 
in these cases, when the blindness has advanced, the pains, too, 
become less severe. But if amaurosis does not come on until 
the ataxy is well developed, no improvement in the latter is likely 
to be noted. 

Atrophy is found more rarely with insular sclerosis and lateral 
sclerosis of the spinal cord; and in general paralysis of the 



THE OPTIC NERVE. 435 

insane, although spinal disease is not always present, atrophy of 
the papilla frequently occurs. 

It is probable that the disease commences at the papilla in spinal 
cases. The ophthalmoscope displays a papery-white or bluish- 
white papilla, which in advanced stages often becomes cupped. 
The retinal arteries are usually extremely reduced in caliber, and 
the veins, too, may be small ; but, again, the retinal vessels may 
differ but little, or not at all, from the normal. 

Symptoms. — Central vision is affected at an early stage in the 
disease, and eccentric contraction of the field usually appears at 
the same time. The contraction may be concentric, or it may 
be more marked in one direction than another, and opinion is 
divided as to the direction commonly first involved. This con- 
centric contraction advances gradually towards the center of the 
field from every side, until it finally engulfs the fixation point. 

Occasionally the affection begins as a central scotoma, accom- 
panied by eccentric defects of the field. Color-blindness is an 
almost constant symptom. As a rule, absolute blindness is 
brought about in the course of a year or two. 

Primary Optic Atrophy of the progressive form just described 
may occur As a Purely Local Disease, without any other defect 
in the system. The prognosis for the sight in such cases is as bad 
as in spinal cases. 

Treatment. — In neuritic atrophy, so long as there are still signs 
of active inflammation, antiphlogistic measures — Heurtelonp's 
leech to the temple, hot footbaths, rest of body and mind, dark 
room, iodid of potassium, and, especially, mercury internally, when 
otherwise admissible — are to be adopted. At a later period hy- 
podermic injections of strychnia (1-30 gr., increased gradually to 
1-20 or 1-18 gr. once a day), and galvanism may be tried. Hypo- 
dermic injections of antipyrin (about 71-2 grains every second 
day) have been given with some benefit in these cases. 

In spinal amaurosis, and in optic atrophy occurring as a local 
disease, strychnia hypodermically and the galvanic current some- 
times improve vision for a time. Phosphorus internally may be 
given. 

The treatment for optic atrophy, due to causes 2, 3, and 4, is to 
be directed to the primary disease. 

The Prognosis is very serious ; for, although every thera- 
peutic measure may have been employed, amaurosis is the ulti- 
mate result as a rule. 



436 DISEASES OF THE EYE. 

Tumors of the Optic Nerve. — These are rare affections. 
They occur at all times of life, but most of the patients are. under 
twenty years of age. The tumor usually commences about the 
middle of the course of the nerve, and often does not extend 
to the bulbar end. The symptoms are : Slowly increasing pro- 
trusion of the eyeball, in a direction most usually directly for- 
wards, or forwards and outwards. The motions of the eyeball 
are not greatly restricted, and the center of its rotation is not dis- 
placed, owing to the tumor being within the cone of the orbital 
muscles. The proptosis is unaccompanied by pain. The sight 
becomes very defective, or is quite lost at a very early stage, from 
interference with the functions of the nerve by the tumor, or by the 
optic neuritis, or optic atrophy, to which it gives rise. The tumor 
is sometimes very soft, so that the eyeball can, as it were, be 
pushed back into it, and the pressure does not cause pain. The 
pupil reacts consensually. The tumor may often be felt by pal- 
pation in the orbit. These tumors being benign, the patient's 
health does not suffer. 

The diagnosis between a new growth of the optic nerve and one 
of its sheaths can hardly be made with certainty; but the exist- 
ence of fairly good vision, while other symptoms are as above, at 
a rather late period of the proptosis, would point to the sheath as 
the seat. Such a diagnosis would be important, for, as a brilliant 
case of Dr. Antill Pockley's ^ shows, it may be possible to re- 
move, by Kronlein's operation, a tumor of the sheath of the optic 
nerve, while preserving not merely the eyeball, but good vision as 
well. 

These tumors are either myxo-sarcomata, or, less frequently, 
endotheliomata, and are usually encapsuled by the sheath of the 
nerve. They are benign, in the sense that they do not lead to 
glandular enlargements or to metastases ; but in rare cases they 
extend into the cranial cavity. 

Treatment. — To remove these tumors there are three methods, 
namely : Removal of the eyeball with the tumor ; Kronlein's opera- 
tion, by means of which the optic nerve tumor may, probably in 
most instances, be removed without the eyeball ; and Knapp's 
operation, also for removal of the tumor without the eyeball. It 
is unnecessary to describe the first of these procedures, which 
follows very much the lines of an ordinary excision of the eyeball, 
except that the optic nerve is divided as far back in the orbit as 
possible. Kronlein's operation will be described in the next chapter. 



THE OPTIC NERVE. 437 

Knapp's operation is as follows : The tendon of the internal 
rectus is divided so as to leave a portion adherent to the sclerotic 
of about 5 mm., the cut end being secured by a suture passed 
through it, to prevent it from retracting into the orbit. The eye- 
ball is then forcibly everted outwards, a strong scissors is passed 
into the orbit, and the optic nerve is divided as close to the optic 
foramen as possible. The globe is now further everted outwards, 
to expose its posterior surface with the tumor attached, and the 
latter is removed by dividing the optic nerve close to the eyeball. 
Finally, the eyeball is reposed, the cut ends of the tendon of the 
muscle united, and the opening in the conjunctiva closed. A 
drawback to this operation is that it is not always possible to be 
certain that the deep portion of the tumor is reached with the 
scissors. 

Hyaline, or Colloid, Outgrov^rths from the optic papilla are 
occasionally met with. Seen with the ophthalmoscope, they pre- 
sent the appearance of bluish-gray, mulberrry-like nodules. Ac- 
cording to Iwanoff's ^ investigations they originate in the lamina 
vitrea of the chorioid at the margin of the papilla, or within the 
area of the papilla ; for the lamina vitrea is often prolonged inta 
the papilla, and takes part in the formation of the lamina cribrosa. 
These outgrowths do not always cause a defect of sight, and 
rarely cause serious blindness. It is often found that a blow 
upon the eye has been received some time previously, and it is 
probable that such a trauma may have to do with the growth by 
rupturing the very brittle lamina vitrea. 

Treatment is of no avail. 

Injuries of the Optic Nerve. — In addition to those injuries 
which result from direct violence with sharp instruments, etc., 
entering the orbit, the optic nerve may be injured by falls on the 
head. Fractures of the base of the skull frequently involve in- 
jury to the optic nerve. But even where no fracture occurs, 
blindness with atrophy of the optic nerve may come on, usually 
only in one eye; and in these cases concussion of the nerve at its 
passage through the optic foramen, or an extravasation of blood 
in the sheath of the nerve, is probably the direct cause of the 
atrophy. 

Hemorrhages from the Stomach, Bowels, or Uterus are ca- 
pable of giving rise to serious and incurable blindness. 

Blindness during or immediately after a severe hemorrhage is 
probably due to insufficient blood-supply to the nerve-centers 



438 DISEASES OF THE EYE. 

and retina, accompanying general exhaustion of the system. For 
such cases the prognosis is favorable. 

But there is another class of cases of very much more serious 
import. In these the defect of vision does not come on for from 
two to fourteen days after the hemorrhage, when the general sys- 
tem is recovering. Even comparatively slight hemorrhages, which 
caused no marked anemia, are said to have been followed by blind- 
ness. The connection between the loss of blood and of sight 
in these cases is not yet clearly made out. Leber inclines to the 
belief that the blindness here is due to an extravasation of blood 
at the base of the skull and into the sheath of the optic nerve ; but 
even then the relationship between this and the stomachic or 
uterine hemorrhage is not made clearer. Papillitis has been several 
times noted with the ophthalmoscope in these cases ; and this cir- 
cumstance makes it probable that neuritis is the immediate cause 
of blindness — even in those cases which show no ophthalmoscopic 
sign of it — and hydremia may be presumed to be the influence 
which calls forth the neuritis. 

The Defect of Vision may be but slight, or it may amount to 
.absolute amaurosis. Both eyes are usually affected in equal de- 
gree. But cases have been observed in which one eye was com- 
pletely amaurotic, while the vision of the other eye was quite 
normal ; and one such case is sufficient to prove that the lesion is 
peripheral — in fact, that it lies in each instance on the distal side 
of the optic chiasma. The field of vision is frequently contracted, 
either concentrically or segmentally ; and even when central vision 
recovers the field may remain contracted. 

The Ophthalmoscopic Appearances which are present immedi- 
ately on the occurrence of the blindness have not as yet been 
observed. A few weeks later they have been found to be dif- 
ferent in different cases. They have been found at this period 
normal ; or presenting slight paleness of the papilla and contrac- 
tion of the arteries ; or there was marked paleness of the papilla, 
and the arteries were extremely contracted, with slight distention 
of the veins ; or paleness of the papilla was present, but its margins 
were indistinct, and the surrounding retina somewhat swollen, 
while the retinal vessels were normal. Small hemorrhages have 
repeatedly been seen in the neighborhood of the papilla. At later 
periods well-marked optic atrophy is frequently observed. 

Prognosis. — If in the beginning the defect of vision be merely 
amblyopia, and not complete blindness, hopes may be entertained 



THE OPTIC NERVE. 439 

of marked improvement or of complete recovery. But Mooren 
has seen slight amblyopia pass into permanent amaurosis. 

Hemorrhages from the stomach are those which are followed 
by the most complete and permanent blindness, while uterine hem- 
orrhages are more commonly followed by less serious degrees of 
blindness. 

The Treatment must consist of internal remedies calculated to 
correct the general anemia, such as iron, beef-tea, and meat ex- 
tracts, wine, etc. Strychnin hypodermically, to stimulate the 
nerve, may be employed. 

Glycosuric Amblyopia. — In addition to the retinal affections 
dependent upon diabetes, we recognize the occasional occurrence 
in that disease of defects of vision which are referred to disorder 
of the optic nerve, and which are not always accompanied by oph- 
thalmoscopic changes. These defects of vision are found in the 
form of (i) General Amblyopia (see p. 430), or, in slighter cases, 
as amblyopia without central scotoma. Occasionally, higher de- 
grees of amblyopia with concentric contraction of the field of 
vision, and yet negative ophthalmoscopic appearances, are present. 
(2) Atrophy of the optic nerve. This may appear in the usual 
form as progressive blindness, with concentric contraction of the 
field of vision ; or it may come on after the slighter form of ambly- 
opia has existed for some time. (3) Hemianopsia and color- 
blindness. 

It is probable that these apparently different kinds of blindness 
depend upon similar pathological processes, and merely indicate 
degrees of the latter. In what these processes consist is still un- 
known ; but the tendency to hemorrhages in the retina in diabetes 
makes it likely that hemorrhages in the optic nerve are sometimes 
the source of the amblyopia in question ; while in the cases with 
central scotoma it is no doubt due to retrobulbar neuritis similar 
to that produced by tobacco, etc. 

Amblyopia is sometimes the only symptom of diabetes ; and, 
consequently, it is of the utmost importance to examine the urine 
for sugar in every case of amblyopia where the ophthalmoscopic 
appearances are negative, or where the only abnormality is 
atrophy of the optic papilla. 

The Treatment indicated is solely that for the general disease, 
and the prognosis for vision depends upon the amenability of the 
latter to treatment, and upon the extent to which organic changes 
in the optic nerve have proceeded. 



440 DISEASES OF THE EYE. 



References. 

* " Trans. Internal. Med. Congress," 1881, vol. iii. p. 52. 
^ " Von Graefe's Archiv," xvii. 2. p. 249. 

^ " Trans. Ophthal. Soc, U. K.", vol. v. p. 149. 

* S. Snell, " Brit. Med. Journ.," March 3, 1894. 

' P. Smith, " Ophthal. Rev.," 1893, p. loi ; and Valude, " Revue d' 
Ophtal.," 1893, p. 231. 

* " The Cerebro-Spinal Fluid, its Spontaneous Escape from the Nose," 
London, 1899. 

^"Australian Medical Gazette," October 21, 1901, and "Archives of 
Ophthalmology,'' xxxi. 2. p. 114. 

* *' Klin. Monatsbl. f. Augenhlk.," vi. p. 425. 



CHAPTER XVIL 

THE ORBITAL MUSCLES AND THEIR 
DERANGEMENTS. 

Normal Action of the Orbital ^Iuscles. 

The eyeball moves round a point on its antero-posterior axis, 
situated (in the emmetropic eye) 14 mm. behind the cornea, and 
10 mm. in front of the posterior surface of the sclerotic. Its 
motions are effected by means of the six orbital muscles, arranged 
in three pairs, each pair consisting of two antagonistic muscles ; 
thus the rectus internus and rectus externus are antagonistic, the 
former rotating the eye inwards, and the latter rotating it out- 
wards. The remaining pairs are the recti superior and inferior, 
and the obliqui superior and inferior. 

The Primary Position of the Eyeball is that one in which, the 
head being held erect, the gaze is directed straight forwards in 
the horizontal plane. This is the starting-point from which the 
actions of the muscles are considered. 

The Rectus Externus and Rectus Internus^ lying from their 
origin to their insertion in a plane which corresponds with that of 
the horizontal plane of the eyeball, move the latter on its perpen- 
dicular axis directly inwards and outwards, and have no other 
action. 

The plane of the Rectus Superior and Rectus Inferior does not 
quite correspond with the vertical plane of the eyeball, and conse- 
quently the axis on which they rotate the globe is not its horizontal 
axis, but one which, passing from within and before, backwards 
and outwards, forms with the antero-posterior axis an angle of 
70° (Fig. 131). While, then, their action is mainly to rotate the 
eyeball upwards and downwards, these muscles rotate it also some- 
what inwards. ^Moreover, the superior rectus giving to the ver- 
tical meridian of the cornea an inward inclination."^ or inward 
wheel-motion of the eye (r<'ide infra), while the inferior rectus 

* In speaking of the inclination of the vertical meridian of the 
it is the upper extremity of this meridian which is 



Z7 



meant. 

441 



442 



DISEASES OF THE EYE. 



gives this meridian an outward inclination or outward wheel- 
motion of the eye, the power of these muscles over the upward 
and downward motions is greatest when the eye is turned out, 
for then their axis of rotation coincides most closely with the hori- 
zontal axis of the globe ; and their influence over the wheel-motion 
is greatest when the eye is turned in, for then their axis of rota- 
tion coincides most closely with the antero-posterior axis of the 
globe. 

The plane of the Oblique Muscles of the eyeball also approaches 
the vertical plane of the eyeball, the axis upon which they rotate 
the latter passing from within and behind, forwards and outwards, 





Fig. 131, 



Fig, 132. 



and making with the antero-posterior axis an angle of 35° (Fig. 
132). The principal action, accordingly, of the oblique muscles 
is to incline the vertical meridian of the cornea ; the sup. oblique 
inclines it inwards (wheel-motion inwards), the inf. oblique in- 
clines it outwards (wheel-motion outwards). In addition to this 
action the oblique muscles, respectively, rotate the eyeball down- 
wards and outwards (sup. oblique), and upwards and outwards 
(inf. oblique) . It is evident that the power of the oblique muscles 
over the upward and downward motions of the eyeball is greatest 
if the eye be turned in, and that their power over the wheel-motion 
is greatest when the eye is turned out. 



THE ORBITAL MUSCLES. 



443 



To sum up, then, the superior obHque and superior rectus pro- 
duce wheel-motion inwards, while the inferior oblique and inferior 
rectus produce wheel-motion outwards. The action of the 
obliques on the wheel-motion is greatest when the eye is rotated 
outwards, and of the recti when the eye is rotated inwards. 

In considering the motions of the eyeballs we have to think of 
the motions of one eyeball as associated with those of its fellow — 





Fig. 133. 

e. g., the action of the internal rectus of the left eye is associated 
with the action of the external rectus of the right eye, in rotation 
of both eyeballs to the right. 

The vertical meridian of the eyes becomes inclined to the right 
or left in different positions of the globes, as was experimentally 
proved by Bonders. 

I. In the primary position, as also when the eyes are turned 
directly to the right, to the left, upwards, or downwards, the ver- 





FiG. 134. 

tical meridians (a, h, Figs. 133-137) maintain their vertical direc- 
tion (Fig. 133). 

2. When the eyes are turned to the left, and upwards, the ver- 
tical meridian of each eye is inclined at the same angle to the left 
(Fig. 134). Wheel-motion to the left. 

3. When the eyes are turned to the left, and downwards, the 
vertical meridian of each eye is inclined to the right at the same 
angle (Fig. 135). Wheel-motion to the right. 



444 



DISEASES OF THE EYE. 



4. When the eyes are turned to the right, and upivards, the ver- 
tical meridian of each eye is inchned at the same angle to the right 
(Fig. 136). Wheel-motion to the right. 

5. When the eyes are turned to the right, and downwards, the 
vertical meridian of each eye is inclined at the same angle to the 
left (Fig. 137). Wheel-motion to the left. 

We shall now consider what muscles of one eye are called into 





Fig. 135. 

action, when an individual requires to place it in the several prin- 
cipal positions. 

1. In the Primary Position all the muscles are at rest. 

2. Motion of the eyeball directly outzvards is effected by the 
external rectus alone, and motion directly inwards by the internal 
rectus alone. 

3. Motion of the eyeball directly upwards and directly down- 
wards is effected chiefly by aid of the sup. and inf. recti. But 





Fig. 136. 

these muscles, acting alone, rotate the eyeball slightly inwards, 
and give a certain inclination to the vertical meridian, which in 
this position should be upright. Consequently, in rotation of the 
globe directly upwards, the inf. oblique, which rotates the eye 
slightly outwards (as well as upwards) and inclines the vertical 
meridian outwards, must be associated with the sup. rectus, in 
order to counteract in these particulars the tendency of its action. 
In rotation of the eyeball directly downwards, the inf. rectus must 



THE ORBITAL MUSCLES. 445 

be associated with the sup. oblique, which acts antagonistically to 
this rectus in respect of rotation inwards and of outward wheel- 
motion. 

4. Rotation upwards and outzmrds is chiefly effected by aid of 
the rectus superior and rectus externus. But the latter muscle 
has no influence over the wheel-motion, while the former produces 
wheel-motion inwards. Yet the inclination of the vertical 
meridian is outwards in this position ; and therefore a third muscle, 
which will supply this inclination in a high degree, is required — 
namely, the inferior oblique, whose power over the wheel-motion 
of the eyeball is greatest when the latter is turned upwards and 
outwards. 

5. Rotation dcmmwards and outwards is chiefly effected by the 
rectus inf. and rectus ext. Inasmuch, however, as the former in- 
clines the vertical meridian outwards, while the latter has no in- 
fluence over it at all, a third force is required which will bring 



about the required inward wheel-motion — namely, the sup. 
oblique, whose influence in this respect is most powerful when the 
eye is turned downwards and outwards. 

6. Rotation upwards and inzvards is chiefly brought about by 
the rectus superior and rectus internus. But the effect of the 
former upon the inward wheel-motion of the eye would be so 
great as to interfere with parallelism of the vertical meridians of 
the two eyes, that of the other eye not being inclined outwards in 
a corresponding degree. A third force, therefore, is required, 
which will to a certain extent counteract the influence of the sup. 
rectus in this respect, and this is the inf. oblique, which in this 
position of the eyeball has but slight power over its wheel-motion. 

7. Rotation downwards and inwards is chiefly the result of 
contraction of the rectus inf. and rectus int. The power of the 
former over the outward inclination of the vertical meridian would, 
in a similar way, be too great, and must be similarly corrected by 
the action of the superior oblique. 



446 DISEASES OF THE EYE. 



The Field of Fixation. 

The field of fixation contains all the points which the eye can 
successively see or " fix " without movement of the head. It can 
be measured with the perimeter, as in testing the field of vision, 
except that here the patient is made to move the eye as far as pos- 
sible in each meridian, and the limit of each movement is meas- 
ured by observing the corneal reflex of a candle flame, or ophthal- 
moscope mirror, which is moved along the arc of the perimeter. 
The binocular field of fixation contains all those points which can 
be seen as single with the two eyes and without movement oi the 
head. According to Landolt ^ the averages give, for movement 
of one eye, inwards 44°, outwards 46°, upwards 44°, and down- 
wards 50°. 

Strabismus. 

When looking at any object with the two eyes it is necessary, 
in order to avoid seeing double, that the visual axis of the eyes 
should meet at the point fixed. When this does not take place, 
one of the eyes must be in a faulty position, or, as it is commonly 
termed, it squints. This condition is called strabismus, and may 
arise either from overaction or from paralysis of one of the 
muscles. Strabismus may occur in any direction, but vertical and 
oblique deviations are less common than the convergent or di- 
vergent forms. 

In order to ascertain in slight cases which of the two is the 
deviating eye, the patient is made to fix a certain object, and one 
of the eyes, say the left, is rapidly covered with the surgeon's 
hand; then, if the right eye make no movement, it must have 
been looking at the object before the left one was covered ; but if, 
on covering the right eye, the left make a movement in order to fix 
the object, then this eye must be the squinting one. The move- 
ment is always in the opposite direction to the deviation. For in- 
stance, if the eye be turned inwards too much, it must of course 
turn outwards to fix the object, when its fellow is covered. An- 
other good method consists in observing the position of the corneal 
reflex when the patient looks at the ophthalmoscope (see Measure- 
ment of Strabismus). But the most delicate test is the character 
of the diplopia, when diplopia is present. 

Apparent Strabismus is due to a large angle y (p. 24). In this 



THE ORBITAL MUSCLES. 447 

case, as the visual axes are both directed to the point fixed, there 
will be no movement of either eye on covering the other, as in 
true strabismus. 

Paralyses of the Orbital Muscles. 

Loss of power of one or more of the muscles of the eyeball is, 
of course, always to be regarded as a symptom, not as in itself a 
disease. 

It may be due to lesions in several different situations, namely: 
(i) Lesions situated in the orbit. (2) Basic lesions — lesions 
situated at the sphenoidal fissure, and those at the base of the skull, 
between the sphenoidal fissure and the pons. (3) Pontine lesions, 
which may be Fascicular — /. e., involving the ocular nerve fibers 
in the substance of the pons, or Nuclear — /. e., only attacking the 
nuclei of the nerves in the aqueduct of Sylvius and floor of the 
fourth ventricle. (4) Cerebral lesions — lesions above the nuclei, 
in the internal capsule, corona radiata, or cortex. These four 
classes differ considerably in their clinical aspect, in their patho- 
logical causes, and in their significance for the w^ell-being of the 
patient. 

The first class — loss of power due to orbital lesions — will be 
considered in the chapters on Diseases of the Orbit. 

The second class — those due to basic lesions — provides by far 
the largest number of cases of paralyses of the orbital muscles. 
Let us now consider the 

General Symptoms of this second class. They include symp- 
toms to be found in each of the other classes. ( i ) Diplopia. The 
affected eye being deviated from its correct position, and being 
more or less incapable of associated motions with the other eye, 
the image of the object looked at is not formed on identical spots 
of the retina in each eye, and hence the object seems doubled. 
(2) Indistinct vision. If the paralysis be but slight, actual 
diplopia may not be present, but the double images overlapping 
each other will cause dimness or confusion of sight. (3) Giddi- 
ness, due partly to the diplopia, and partly to faulty projection of 
the object. By faulty projection is meant the false idea of the 
position of the image in the field of fixation. (4) Some patients 
turn the head towards the side of the paralyzed muscle, in order 
to diminish or eliminate the diplopia — e. g., if the left ext. rectus 
were paralyzed, the head would be turned towards the left; if it 



448 DISEASES OF THE EYE. 

were the left int. rectus, the head would be turned towards the 
right. By this maneuver the loss of the action of the affected 
muscle is less felt for those objects which lie straight in the 
patient's path, while he walks about ; because it involves a rota- 
tion of the eye towards the side of the healthy antagonist, in which 
region of the binocular fixation field the diplopia is reduced to a 
minimum. Some patients close one eye to procure single vision. 
(5) In peripheral paralysis it is most common to find only the 
muscle, or muscles, supplied by some one nerve — the third, fourth, 




^'.' f a' 

Left Eye. Right Eye. 

Fig. 138. 

or sixth — affected ; although, of course, exceptions to this are not 
rare, especially where a neoplasm form.s at the base of the skull. 

In studying a case of paralysis of an orbital muscle the follow- 
ing General Principles should be borne in mind: (i) The de- 
fective mobility and the diplopia increase towards the side of the 
affected muscle — towards the left, if the left external rectus be 
paralyzed ; towards the right, if the left internal rectus be para- 
lyzed. (2) The secondary deviation (/. e., the deviation of the 
sound eye while the affected eye fixes) is greater than the primary 
deviation (i. e., the deviation of the affected eye while the sound 
eye fixes) ; because the muscle in the sound eye, which is asso- 
ciated in its action with the paralyzed muscle in the affected eye 
{e. g., the rect. int. with the rect. ext.), must receive a nervous im- 



THE ORBITAL IMUSCLES. 449 

puls€ of equal intensity to that sent to the weak muscle, and, as the 
latter requires a considerable impulse to excite its action, its asso- 
ciate will be overexcited. Let us suppose the left external rectus 
to be paralyzed, and that, shading the right eye with a hand, we 
direct the patient to fix with his left eye an object held somewhat 
to his left-hand side ; we may notice, on removing the shading 
hand, that the right eye has been rotated inwards to an extent far 
exceeding that of the primary deviation of the left eye, and has 
now to make an outward motion in order again to fix the object. 
(3) The image formed on the retina of the affected eye is pro- 
jected (i. e., seems to the patient to lie) in the direction of the 
paralyzed muscle — e. g., if the left ext. rect. be paralyzed, the 
image corresponding to that eye will be projected to the left of the 
image belonging to the right eye. 

Where the image of the affected eye lies to the corresponding 
side the diplopia is termed homonymous, and homonymous double 
vision always indicates convergence of the visual lines. Fig. 138 
explains the occurrence of homonymous diplopia in convergent 
paralytic strabismus.* The right eye fixes the object 0, and its 
image on the macula lutea ni; but the left eye, by reason of the 
paralysis of the external rectus, is turned in, and its visual axis 
lies in the direction in v, and the image of falls to the inner side 
of the macula lutea at a. Now why should this image not be 
referred to its correct position along the line a of The reason is 
that the patient is not conscious of the deviation of this eye ; and, 
having always been in the habit of superposing his fields of vision, 
so that the visual axes of the eyes meet at the object fixed, he 
imagines that this is still the case, and that v m lies in the position 
of a, and that the macula lutea m is at //?'. But if this were the 
case, a would be at a' , and in this position of the eye, indicated by 
the dotted line, images formed at a' to the inner side of the macula 
lutea are projected to the outer side of the field, along the line 
a' 0' , and the patient imagines that occupies the position 0' , as 
seen with the left eye. 

If we suppose the internal rectus of the left eye to be paralyzed, 
the image on the retina of that eye falls then to the outside of its 
macula lutea, and must therefore be projected to the right of the 
true position of the object; this is crossed diplopia, and attends 
divergence of the visual lines. 

* For the sake of simplicity in the diagram the effect which rotation 
of the eye has on the nodal point is omitted. 

38 



450 DISEASES OF THE EYE. 

Paralysis of the External Rectus of the Left Eye. — If this 
be complete or considerable, it is easy of diagnosis, as marked loss 
of power and motion of the left eyeball outwards is present, and 
Lhe patient complains of double vision. He keeps his head turned 
to the left, in order to diminish the influence of the paralyzed 
muscle as much as possible. 

If, however, the paralysis be but slight, the patient may not 
complain decidedly of diplopia, but only of indistinctness or con- 
fusion of sight, especially when he looks towards the left. To 
decide the diagnosis in such a case, the double images must be 
examined. A long lighted candle is used as the object to be looked 
at; and one eye — let us say here the left eye — is covered with a 
bit of red-stained glass in order to differentiate the images.* The 
candle is now held on a level with the patient's eyes, and straight 
opposite him, at about three meters' distance (eyes in primary 




Fig. 139. 

position), (a) In this position the images are seen very close 
together or overlapping each other, both of them upright and on 
the same level, the red candle to the left, the white to the right — 
i. e., homonymous diplopia = convergence. This convergence 
must be due to paralysis of one or other external rectus muscle, 
but we cannot say at this stage of the experiment which of them 
is affected, {h) In order to determine this point the candle must 
be carried from side to side, and the increasing or decreasing dis- 
tance of the images from each other noted. If the candle be 
carried slowly to the right, the patient following it with his eyes 
without turning his head, the images come still closer together, or 
only one candle is seen. But if the candle be carried to the 
patient's left-hand side, the images go farther apart, their rela- 
tive positions being maintained. We now know that it is the left 

* Maddox' Rod Test, described further on, is very suitable here, and 
in the investigation of other forms of ocular palsy. 



THE ORBITAL MUSCLES. 451 

external rectus which is affected : because towards the left — the 
direction in which the action of this m,uscle is most wanted, and 
consequently its loss most felt — the distance between the double 
images increases. The images are erect, as no wheel-motion is 
caused by action of the external rectus, (c) If, however, the 
candle be held to the left and raised aloft, the image belonging to 
the left eye will seem to lean away from that of the right eye 
(Fig. 139). The reason of this is that, owing to the paralysis of 
the external rectus, the left eye cannot look upwards and out- 
wards as it should, but merely looks upwards. The vertical 
meridian therefore remains vertical. But the right eye, which is 
free to follow the candle, looks up and to the left. Its vertical 
meridian is therefore inclined to the left. That is, the vertical 
meridians of the two eyes converge at the top, which necessitates 
a divergence of the upper extremities of the images. The rota- 
tion of the right eye in this position is physiological, and its image 
is therefore judged to be vertical; while the image of the left eye 
diverging from that of the right, though really vertical, is judged 
to be oblique. An analogous derangement of the vertical 
meridian takes place in the position below and to the outside. 
(d) If the patient be told to direct his gaze specially towards the 
red candle — i. e., the image which belongs to the left, the affected, 
eye — the distance between the two candles will be much greater 
than if he direct his gaze towards the white candle. This is ex- 
plained by General Principle No. 2 (p. 448). 

If the patient's good eye be closed, and an object (surgeon's 
finger) be held up within his reach, but towards his left-hand side, 
and he be requested to aim rapidly at it with his forefinger, he will 
aim to the left of it. The nervous impulse sent to his left ex- 
ternal rectus, to enable him to turn the eye towards the object, is 
of such intensity as to lead him to fancy that the object lies much 
farther to the left than is the case (incorrect projection of the 
field of view) ; for we, to a great extent, estimate the distance of 
objects from each other by the amount of nervous impulse supplied 
to our orbital muscles in motions of the eyeball. 

A prism held horizontally before the affected eye with its base 
outwards brings the double images closer together ; or, if the cor- 
rect prism be selected, the images will be blended into one. 

Paralysis of the Superior Oblique of the Left Eye. — This 
paralysis will be most apparent when a demand is made for motion 
of the eyeball downwards and inwards, motion in this direction 



452 DISEASES OF THE EYE. 

being that over which the superior obHque has most influence. 
Yet absolute defect of motion is sometimes difficult to detect even 
in complete paralysis of this muscle, owing to vicarious action of 
the inferior rectus and of the internal rectus. Careful examina- 
tion of the secondary deviation will often be successful as to this 
point, but it is on the examination of the double images that we 
must chiefly rely for the diagnosis. 

(a) In the whole of the field of vision above the horizontal 
plane there is single vision. Belov/ the horizontal plane in the 
median line diplopia appears, the image belonging to the left eye 
standing lower than that belonging to the right, because the su- 
perior oblique being a muscle which assists in rotating the eye 
downwards, the latter, for want of the action of this muscle, now 
stands higher than its fellow (right eye), and consequently the 
image will not fall on its macula lutea (as it does in the right eye), 







Fig. 140. 



but above it, and will therefore be projected below the image of 
the right eye. The position downwards and inwards of the eyeballs 
is that in which the greatest demand is miade upon the superior 
oblique for rotation of the eye downwards : therefore it is in this 
position its want for this purpose is most felt ; and when the candle 
is held in this position the vertical distance between the double 
images is greatest, (b) The superior oblique assists also in rota- 
tion of the eye outwards : therefore loss of its power must commit 
the eyeball to a certain extent to the power of the muscles which 
move it inwards, and a rotation in this latter direction (con- 
vergence) takes place, with the result of making the image belong- 
ing to the left eye stand to the left of the image belonging to the 
right eye (homonymous diplopia), (c) The superior oblique 
inclines the vertical meridian inwards: therefore, in rotation di- 
rectly downwards, loss of its power commits the eye to the out- 
ward wheel-motion imparted to it by the inferior rectus. This 



THE ORBITAL MUSCLES. 453 

gives to the image belonging to the left eye an inclination to the 
patient's right hand, (d) The power of the superior oblique to 
incline the vertical meridian inwards is greatest when the eye is 
turned downwards and outwards : consequently, in this respect its 
paralysis will be most felt in this position, and therefore here the 
inclination of its image to that of the sound eye will be most 
marked, (e) A remarkable phenomenon usually noticed in this 
paralysis (and sometimes in paralysis of the inferior rectus), and 
for which a good explanation does not exist, is that the image be- 
longing to the affected eye seems to stand nearer the patient than 
that of the sound eye. 

To sum up, then (vide Fig. 140) : below the horizontal plane 
there is homonymous diplopia, while the image (A) of the affected 
eye stands on a lower level, is inclined towards the other image, 
and seems to be nearer the patient. Furthermore : 

(/) In an extreme lower and outer position the image of the 
affected eye may sometimes seem to stand higher than that of the 



.:ru 



r^. 



L' II'' 

Fig. 141. Fig. 142. 

Fig. 141. — Paralysis of left sup. oblique. Homonymous diplopia. R, image 

of right eye. L, image of left eye. 
Fig. 142. — Paralysis of right inferior rectus. Crossed diplopia. R', image 

of right eye. L', image of left eye. 

sound eye, owing to an excessive outward inclination of the ver- 
tical meridian, which throws the image on the lower and outer 
quadrant of the retina. 

In order to do away with or to diminish the diplopia, the patient 
inclines his head forwards, and turns it to the side of the good 
eye. 

For the prismatic correction of the diplopia, two prisms will 
be required ; one with its base downwards in front of the left eye, 
to correct the vertical difference, and a second with its base out- 
wards in front of the right eye, to correct the lateral difference. 

To make the diagnosis between the foregoing paralysis and 
paralysis of the right inf. rectus (in which the diplopia is also be- 



454 DISEASES OF THE EYE. 

low the horizontal plane only, and the false image lower than the 
true one and inclined towards it) it has merely to be remembered 
that there is here crossed — instead of homonymous — diplopia, be- 
cause the superior oblique, which now chiefly effects the down- 
ward motion of the eyeball, turns it at the same time somewhat 
outwards. The Figures 141 and 142 will assist in this explana- 
tion. 

Paralysis of the Internal Rectus, Superior Rectus, Inferior 
Rectus, Inferior Oblique, and Levator Palpebrae. — Complete 
paralysis of all the branches of the third nerve produces a remark- 
able appearance. The upper lid droops (ptosis), the pupil is 
semi-dilated and immovable, the power of accommodation is de- 




FiG. 143. 

stroyed, and the eyeball is often slightly protruded, owing to the 
backward traction of the recti being lost to it. Motion inwards 
exists but to a slight degree, and motion downwards is effected 
only by aid of the superior oblique, and is accompanied by marked 
inward wheel-motion. If the paralysis be of some little standing, 
the external rectus obtains rule over the eyeball, and rotates it per- 
manently outwards. 

The diagnosis, then, in cases of complete paralysis of all 
branches of the nerve is easily made ; but not so, sometimes, if the 
paralysis be only slight. The examination of the double images, 
then, is of value. If (see Fig. 143) the left third nerve be par- 
tially paralyzed in all or most of its branches, there will be crossed 
diplopia either in the whole of the field of vision — for want of 



THE ORBITAL MUSCLES. 



455 



power in the internal rectus — or towards the patient's right at the 
least, and the lateral distance between the images will increase as 
the visual object is carried farther towards the right. When the 
visual object is held aloft the left eye will remain behind — for 
want of the action of both of the muscles which turn the eye up- 
wards — and, consequently, in this position its image will stand, 
not only to the right of, but also above that of the right eye ; while, 
when the visual object is held below the horizontal plane, the eye 
will — owing to paralysis of the inferior rectus — remain higher 
than the right eye, and consequently its image will appear to be 
lower than that of the right eye. It will, moreover, be inclined 



Left 
Sup. Beet 

Left 
I/?f. Rect 


>■ 1 \ < 


Hip. Rcct. 

hicjht 

Inf. Rect 



Left 
L^f Oht. 



Left 
Sup. Obi. 



Liight 
Ln{. Ohl. 



Right 
Sup. Obi. 



Fig. 144. 



Fig. 145. 



towards the latter image, in consequence of the inward wheel- 
motion imparted to the eye by the healthy superior oblique. 

When in each eye some branches of the third nerve are para- 
lyzed the diagnosis is often extremely complicated. The ptosis, 
however, which is nearly always present, and is readily recog- 
nized, and the paralysis of the sphincter iridis (mydriasis) and of 
accommodation, which often exist, and are also easily observed, 
give valuable aid. Moreover, any loss of motion upwards must 
be due to paralysis of the third nerve ; but if there be loss of 
motion downwards, the differential diagnosis between paralysis of 
the inferior rectus and of the superior oblique has to be made. 
For this see the paragraph on paralysis of the latter muscle. 

As may be imagined from the foregoing, it is often difficult in 
practice to keep clearly before one's mind the different actions 



456 DISEASES OF THE EYE. 

of the orbital muscles, and from the character of the diplopia to 
deduce the paralysis which may be present. An aid in this respect 
has been provided by Dr. Louis Werner ^ by means of two dia- 
grams (Figs. 144 and 145). 

The form of diplopia which characterizes paralysis of each 
muscle is expressed by the position of the dotted line bearing the 
name of the muscle. The dotted lines represent the false images, 
the continuous Imes the true images.* 

In the case of the recti (Fig. 144) the false images inclose a 
lozenge-shaped space situated between the true ones, whereas in 
the case of the oblique muscles (Fig. 145), the true images, which, 
for the sake of simplicity, are combined in one line, lie between the 
four false images, which diverge from one another so as to form 
an X. It will also be noted that the dotted lines extend upwards 
and downwards beyond the others, indicating respectively that 
the false images are higher or lower than the true ones. Another 
fact which the diagrams indicate is that, in the case of the muscles 
represented in the upper halves of the figures, the diplopia occurs 
in the upper part of the field of fixation, or, in other words, in 
upward movements of the eyes. A similar rule holds good with 
regard to the lower halves. 

The method of using the diagrams will be better understood by 
taking a particular muscle as an example. Suppose, for instance, 
that we wish to know what kind of diplopia results from paralysis 
of the left inferior rectus, it is simply necessary to look at the left 
inferior portion of Fig. 144 (recti), which gives the diplopia. If 
we analyze this we find ( i ) that the diplopia is crossed, for the 
false image corresponding to the left eye is on the right of the 
true image — i. e., the right image corresponds to the left eye; (2) 
that the false image has its upper end inclined towards the true 
one; (3) that the false image is lower than the true one, for the 
dotted line extends lower than the other one ; (4) that the diplopia 
occurs in doumzvard movements of the eyes, for it is in the lower 
half of the diagram that the false image lies. 

The same method applies to the other recti : the diplopia for the 
right upper rectus is found in the right upper quadrant, and so 
on for the rest. 

The same rules also apply to the obliques (Fig. 145), with one 
difference. The recti move the eye in the direction indicated by 

* The " false image " corresponds to the affected eye, and the " true 
image " to the sound eye. 



THE ORBITAL MUSCLES. 457 

their names, the superior moving it upwards and the inferior 
downwards ; but in the case of the obliques the reverse takes place, 
the superior oblique moving the eye downwards and the inferior 
upwards. Therefore, for the superior obliques we must look at 
the lower half of Fig. 145, and for the inferior obliques at the 
tipper part. 

Thjs is an extremely simple method. By bearing the figures 
in mind it is possible to tell immediately what kind of diplopia 
would result from paralysis of any one of these muscles, and 
conversely, given the diplopia, to determine to which muscle it is 
due. 

The Causes of Peripheral Paralyses of Orbital Muscles are 
chiefly of rheumatic or syphilitic nature. 

Rheumatic paralysis, to which the external rectus is specially 
prone, will be noted if there are symptoms of general rheumatism, 
or if there is a history of exposure to cold or wet immediately 
preceding the attack. 

SyphiHs will be suggested as a cause if there be a specific his- 
tory, and that other causes can be excluded. Peripheral paralyses 
of the orbital muscles due to syphilis are amongst the later symp- 
toms of the disease, and may depend on exostoses or gummata at 
the base of the skull, or to syphilitic neoplasms, or meningitis, in 
the course of the nerve. The third nerve seems to be particularly 
liable to be attacked by a solitary gumma at the base of the skull, 
especially at the sphenoidal fissure, ptosis being commonly the first 
symptom. 

Other neoplastic growths can, of course, cause these paralyses 
in the same way. 

Prognosis. — In peripheral paralyses recovery is very frequent; 
much, however, depending on the nature of the lesion. In cases 
where a cure is not effected, the antagonist muscle often becomes 
contracted, and the eye is then rotated permanently and excess- 
ively in the corresponding direction. In cases of old standing, a 
permanent contraction of the muscles of the neck may be brought 
about, from the inclination of the head which the diplopia has 
obliged the patient to adopt. 

Treatment. — In these cases the medical treatment consists in 
drugs suitable to the fundamental disease (rheumatism, syphilis, 
etc.). Local depletion at the temple by the artificial leech in the 
early stages, and galvanism later on, may be employed with ad- 
vantage. The most common method of applying galvanism is 



458 DISEASES OF THE EYE. 

through the closed lid; but it is probable that the episcleral 
method — i. e., with the electrode placed directly over the 
muscle — is more effectual. Dr. Buzzard's method ^ seems 
to be a very admirable one. He applies a moistened plate 
rheophore to the nape of the patient's neck, and connects 
it with one pole of a Leclanche battery. He then takes the 
other rheophore, well wetted, in his left hand, and, securing good 
contact with the skin of his palm, applies the index finger of his 
right hand to the patient's globe in the situation of the various ex- 
ternal muscles of the eye. The finger is covered with a single 
thickness of well-moistened muslin, and the conjunctiva should 
be previously rendered insensitive by cocain. The strength of the 
current advised is from 1.5 to 2 milliamperes, and the alternate ap- 
plication and lifting of the finger, by closing and opening the 
circuit, gives rise to a feeling of a slight electric shock in the ter- 
minal point of the finger. The operator should first test the 
strength of the current upon the patient's cheek. The point of 
the finger thus employed acts as a sentient rheophore, and can be 
applied with nicety and delicacy to various parts of the eye, the 
operator being constantly aware, by the feeling in his finger, of 
the strength of the current employed. 

Passive orthoptic treatment ^ occasionally gives a rapid and 
brilliant result, while, again, it is useless. It is performed as fol- 
lows : The conjunctiva at the corneo-scleral margin, near the 
insertion of the paralyzed muscle, is seized with a forceps, and the 
eyeball is drawn in the direction of the muscle, and as far as pos- 
sible beyond its ordinary limit of contraction, and back again. 
These movements are continued for about a minute once a day, 
cocain being used. 

Prismatic glasses may be used, either to eliminate the diplopia 
or to excite the weak muscle to exert itself. In the former case 
the glass selected must completely neutralize the diplopia ; but as 
it can do so only for one position of the eyes, prisms are rarely 
employed in this way. In the latter case a prism slightly weaker 
than that sufficient to completely neutralize the diplopia is selected, 
in order that, with a little effort, the weak muscle may be enabled 
to bring about single vision, and this effort having been success- 
fully maintained for some days, a still weaker prism is then pre- 
scribed, and so on. 

It is very important for the patient's comfort while awaiting 
his cure, unless a cure by prisms as above described is being at- 



THE ORBITAL MUSCLES. 459 

tempted, that the affected eye should be covered, so that the dis- 
tressing double vision may be obviated. 

Surgical treatment is justifiable only when other means have 
failed to restore muscular equilibrium. If the deviation amount 
to 3 or 4 mm., tenotomy of the antagonistic muscle, with subse- 
quent tenotomy of the associate muscle in the other eye, will be 
sufficient; but if the deviation amount to 5 or 6 mm., advancement 
of the paralyzed muscle, in addition to the tenotomy, may be re- 
quired. This surgical treatment applied to the internal and ex- 
ternal rectus sometimes gives satisfactory results ; but in the cases 
of the superior and inferior recti it is less useful, while the oblique 
muscles should not be operated on. 

A peculiar and rare form of peripheral or basal paralysis is 
Intermittent Paralysis of the Third Nerve of one Eye, for 
which Charcot suggested the name of Ophthalmoplegic 
Migraine. The patients are generally children or young adults, 
who usually suffer from headache on the side corresponding to 
the paralyzed eye, and sometimes from vomiting. The paralysis 
may be complete or partial, and the attack varies in its duration 
from a few days to a few months. Some cases are purely periodical 
— i. e., in the intervals between the attacks of paralysis all the 
muscles supplied by the third nerve act in a completely normal 
manner; while in other cases these muscles, or some of them, do 
not completely recover their functions in the intervals. We are 
as yet quite in the dark as to the cause of these periodical paralyses 
of the third nerve. Some hold that the purely periodical cases are 
of a functional nature, possibly hysterical or reflex, and that the 
periodically exacerbating cases alone are due to a lesion of the 
root of the nerve, of an undefined kind, at the base of the skull ; 
while others are of opinion that both forms depend upon a dis- 
eased process at the base. In three cases in which an autopsy was 
made, there was disease of the trunk of the nerve at the base of 
the skull. 

In intermitting paralysis the Prognosis of the purely periodical 
form is favorable, inasmuch as the attacks in the course of time 
become fewer and less severe, until, finally, they cease entirely. 
In the exacerbating form the prognosis for complete recovery is 
less favorable. Out of twenty-six cases collected by Darquier 
only one patient died from a cerebral cause. 

In view of the obscurity which still surrounds the causation of 
these intermitting paralyses their Treatment must consist, in each 



46o DISEASES OF THE EYE. 

case, in the relief of any general dyscrasia or concomitant symp- 
toms which may be present. 

The third class of paralyses of orbital muscles above enumer- 
ated — those due to lesions of the nuclei of the orbital muscles in 
the aqueduct of Sylvius and floor of the fourth ventricle — are 
known by the term 

Ophthalmoplegia Externa, and also as Nuclear Paralysis. — 
The first of these terms was originally employed to denote those 
remarkable cases in which, all, or nearly all, of the orbital muscles 
of both eyes are paralyzed, while the intra-ocular muscles often 
remain intact. There can be no doubt, however, that these cases 
do not differ in their nature from many of those in which, in one 
eye, several orbital muscles supplied by different nerves — e. g., 
third and fourth — are wholly or partially paralyzed ; or where all 
the orbital muscles in one eye are wholly or partially paralyzed; 
or where in each eye muscles supplied by the same nerve — e. g., 
both sixth nerves — are wholly or partially paralyzed ; for such 
cases are often mild forms of the disease, or else stages in its de- 
velopment. At one time it was considered essential for the diag- 
nosis that the intra-ocular muscles should retain their functions, 
but cases occur in which the sphincter iridis and ciliary muscle 
are paralyzed. 

When these two latter muscles alone are paralyzed, the condi- 
tion is called Ophthalmoplegia Interna. When both they and 
groups of orbital muscles are paralyzed, the terms Ophthalmo- 
plegia Interna et Externa, or Ophthalmoplegia Universa, are 
employed. 

The term Nuclear Paralysis indicates any orbital paralysis due 
to a lesion of the nuclei of the orbital nerves in the pons, and 
ophthalmoplegia externa comes within this category. 

Ptosis, even in cases of complete binocular ophthalmoplegia 
externa, is often incomplete, and it is remarkable that in some 
chronic cases, without any improvement in the condition itself, the 
diplopia, which was at first present, quite disappears. 

Occurrence and Progress. — The condition may be congenital, 
or may make its appearance soon after birth, and may remain per- 
manently without becoming complicated with any further disturb- 
ance. Congenital ptosis, which is frequently combined with loss 
of power in the superior rectus, and is usually binocular, is of this 
nature. But Nuclear Paralysis is more commonly seen as an 
acquired condition in childhood, or in adult life, either in an acute 



THE ORBITAL MUSCLES. 461 

or chronic form. iMarked cerebral lethar^- is often seen with 
both forms, and the tendon reflexes may be defective. 

Acute Xuclear Paralysis is due either to an acute inflam- 
matory process in the nuclei — comparable to the process which 
produces poHomyelitis anterior acuta, and hence it is called by 
Byrom B ram well poliomyelitis acuta — or to hemorrhagic lesions. 

The acute inflammator}- cases are apt to have a sudden onset, 
attended with fever, headache, vomiting, and convulsions, which 
may subside after a few days, leaving only the ophthalmoplegia 
behind; and this, too, after a lengthened period, may undergo 
cure, partial or complete. Sometimes these attacks are compli- 
cated with paralysis of the facial ner^-e, or the diseased process 
may extend to the spinal cord, and the symptoms of acute polio- 
myelitis become developed; or, again, acute bulbar paralysis may 
come on. 

Acute peripheral neuritis of the ocular ner^'es, which is some- 
times seen in cases of alcoholic poisoning, may be confounded 
with acute nuclear palsy. The symptoms of the two states are 
the same, except that in the case of peripheral neuritis there are 
no head symptoms at the commencement. 

The onset of acute hemorrhagic ophthalmoplegia is sudden, but 
is unattended by headache, vomiting, or convulsions. It takes 
different courses. Sometimes it is rapidly fatal ; again, it goes on 
to softening of the nuclei, and becomes chronic; while, again, it 
undergoes a slow cure. 

It is extremely probable that to this hemorrhagic class the paral- 
yses of orbital muscles belong, which sometimes follow on an at- 
tack of diphtheritic sore-throat. These paralyses appear in from 
one to six weeks after the outbreak of the primary affection. The 
latter need not have been of a severe kind ; indeed, sometimes 
patients are unaware that they have had a sore throat. These 
diphtheritic paralyses always recover in the course of some weeks. 

In diabetes, paralyses of orbital muscles are not very uncom- 
mon, and are probably to be classed as nuclear. The same may 
be said of orbital paralyses in lead-poisoning and in influenza. 
Other causes are cold, poisoning by nicotin, sulphuric acid, car- 
bonic oxid, and tainted meat. 

The Prognosis in all these instances is favorable. 

Chronic Nuclear Paralysis (Chronic Poliencephalitis Superior, 
of Wernicke) is much more common than the acute form. It de- 
pends on a degenerative atrophy of the nerve nuclei, analogous to 



462 DISEASES OF THE EYE. 

that which occurs in progressive muscular atrophy and in chronic 
bulbar paralysis. The onset is gradual, the loss of power in the 
muscles being at first very slight, but ultimately complete paralysis 
of the affected muscles results. There is no fever, nor any cere- 
bral symptom. The condition may become associated with 
chronic bulbar paralysis, with progressive muscular atrophy, or 
with locomotor ataxy. But this is not so liable to occur in infants 
as in adults. 

In some cases there may be partial paralysis of the orbicularis 
palpebrarum, which, according to Mendel, is innervated from the 
third-nerve nucleus through the facial nerve, along with other 
muscles of the oculofacial group (frontalis and corrrugator 
supercilii). 

Coarse lesions, especially tumors of the pons and of its neigh- 
borhood which press on it, may produce orbital paralyses closely 
simulating those due to nuclear lesions. But here the paralysis 
is only one of the symptoms in the case, which are likely to include 
headache, vomiting, optic neuritis, hemianopsia, hemiplegia, etc. 
Softenings, patches of disseminated sclerosis, and internal hydro- 
cephalus with overdistention of the aqueduct of Sylvius, are other 
lesions which may give rise to similar orbital paralyses, but which 
cannot be regarded as true nuclear ophthalmoplegia. The mode 
of onset, and the concomitant symptoms, of each case must serve 
as our guides in arriving at a diagnosis, which will sometimes be 
difficult enough. 

Conjugate Lateral Paralysis of the eyes is a symptom which 
may be caused by a lesion in the pons. We believe that the volun- 
tary motor impulses, coming down from the cortex to produce 
associated lateral motions of the eyeballs — i. e., action of the ex- 
ternal rectus of one eye, along with action of the internal rectus of 
the other eye — first reach the nucleus of the sixth nerve, and then 
pass on, through fibers called the posterior longitudinal bands, 
under the corpora quadrigemina, and join with the fibers of the 
opposite third pair for the supply of the internal rectus of that 
side. The sixth pair of one side supplies in this way the external 
rectus of its own side, and to a slight extent the internal rectus of 
the opposite side ; and it is quite probable that similar decussa- 
tions may exist in the nerve supply of other orbital muscles. 
Hence a lesion at, let us say, the left sixth nerve nucleus would 
paralyze the conjugate lateral motions of the eyes towards the I'^ft 
side; and there would in consequence be conjugate lateral devia- 



\ 



THE ORBITAL MUSCLES. 463 

tion of the eyes towards the right — the eyes looking away from 
the lesion. In conjugate paralysis, or deviation, whether due to a 
pontine lesion, or, as in a later paragraph, to a cerebral lesion, the 
combined action of the internal recti for the purpose of con- 
vergence of the eyes is retained. 

Paralysis of the orbital muscles from nuclear disease may 
occur in Locomotor Ataxy, disseminated Sclerosis, General 
Paralysis, and more rarely in Exophthalmic Goiter and Severe 
Multiple Neuritis. 

Fascicular Paralyses are mainly distinguished by the presence 
of other symptoms due to involvement of neighboring structures. 
They are rarely symmetrical. Vertigo is common with fascicu- 
lar third-nerve paralysis, owing to implication of the red nucleus 
in the tegmentum which is connected with the superior peduncle 
of the cerebellum. 

In Myasthenia Gravis the symptoms include some which are 
due to derangement in the power of orbital muscles. A very 
complete account of the disease was published by Buzzard,^^ and 
Harry Campbell and Edwin Bramwell ^^ have also published a 
paper on the subject. As regards the eye-symptoms, these latter 
authors state : Ptosis is a common symptom ; it is usually 
bilateral and more marked on one side than on the other. It may 
be constant, or it may only be present towards the latter end of 
the day, or if the patient looks up for any length of time, when 
the lids gradually fall. Owing to weakness of the occipito-fron- 
talis, their compensatory overaction, so common in other forms of 
ptosis, cannot occur. Weakness of the orbital muscles with re- 
sulting diplopia is often present. Sometimes one muscle is more 
affected than others, sometimes there is a general paresis affecting 
?A\ the orbital muscles, while in some cases complete and persistent 
ophthalmoplegia externa has been present. An alteration in the 
relative position of the two images is a striking feature. In some 
cases irregular nystagmoid movements are induced upon con- 
jugate lateral motion of the eyes. The ocular muscles, as is the 
case with other voluntary muscles, become readily fatigued, the 
patients complaining that after reading a few lines the words and 
letters run into each other. Pupil changes are exceptional, but 
they are sometimes unequal. In Buzzard's case, after prolonged 
convergence, the pupils showed a tendency to oscillatory move- 
ments. The power of accommodation does not become fatigued. 

The general features of the disease are : Weakness of some or 



464 DISEASES OF THE EYE. 

all of the voluntary muscles of the body, which may amount to 
complete paralysis. After a long rest — e. g., the first thing in the 
morning — they may respond normally to the will, but become 
rapidly exhausted after a little use. The affected muscles often 
exhibit the myasthenic reaction, becoming exhausted by faradic 
stimulation. The entire system of voluntary muscles may be 
affected, but those muscles are most apt to be implicated which 
normally act most constantly, such as the cervical muscles and 
the extrinsic muscles of the eyeball. The symptoms fluctuate 
from day to day, or from month to month, and may even disap- 
pear for months or even years, and reappear. There are no sen- 
sory symptoms. Death occurs in a large proportion of the cases, 
but no structural changes have been found to account for the 
symptoms. 

Cerebral Paralysis of Orbital Muscles form the fourth and 
last of the classes enumerated. They include all the orbital 
paralyses due to lesions above the nuclei — i. e., in the cortex, 
corona radiata, or internal capsule. They are usually associated 
with other symptoms, which aid us in localizing, more or less ac- 
curately, the lesions which cause them. These paralyses are 
always physiological, associated, or conjugate, as they are vari- 
ously and with equal correctness termed — they are, in short, paral- 
yses of motion rather than of muscles. 

Conjugate lateral paralysis — loss of power of motion of the eyes 
to one side or to the other, while the power of convergence of the 
optic axes is retained — is by far the most common form of this 
symptom. We do not as yet know where the cortical center for 
the associated lateral motions of the eyes is situated.* But even 
if we did know its position, it is not likely that much would be 
gained so far as clinical localization of the cerebral lesion is con- 
cerned ; for this center, wherever it may be, is extremely sensi- 
tive, and is apt to be thrown out of gear by lesions of many dif- 
ferent parts of the cortex. Conjugate deviation is, in short, very 
apt to be a distant symptom, especially in cerebral hemorrhage, 

* This center has been placed b}^ various authors in the inferior parietal 
lobule (Wernicke, Henschen, Munk, etc), and in the second frontal 
convolution (Ferrier, Horsley, and Beevor), Stimulation of the centers 
of vision in the occipital lobe has also been found to produce conjugate 
movements (Schaefer, Munk), and these have been regarded as reflex 
by some ; but Knies holds that the visual center contains the m.otor center 
for the eye-muscles as well. Moreover, it is stated that the visual cortex 
contains motor pyramidal cells. 



THE ORBITAL MUSCLES. 



465 



when it is often accompanied by a rotation of the head in the same 
direction, and lasts only a short time. Moreover, it is thought 
that, when this center may happen to be actually involved in the 
lesion, its function, being largely bilateral, is rapidly taken up by 
the opposite hemisphere; and hence, even when conjugate lateral 
deviation plays the part of a direct cortical symptom, it rarely can 
be recognized as such, owing to its evanescent character. In 
paralyzing lesions the deviation of the eyes is of course towards 
the side of the lesion — the eyes look at the cerebral lesion, as Pre- 
vost has expressed it — while in irritating lesions the spasm of the 




I. Left Ext. Rectus; 2. Left Int. Rectus; 3. Right Int. Rectus; 4. Right 
Ext. Rectus; 5. Nucleus left third nerve; 6. Nucleus right third nerve; 
7 and 8 Post, longitudinal bands from sixth nerve to opposite third nerve; 
9. Nucleus left sixth nerve; 10. Nucleus right sixth nerve; 11 and 12. 
Left and right cortical centers. An impulse starting from 12 would travel 
down to 9, and produce an associated movement of the eyes to the left. 



affected muscles causes the deviation to be from the side of the 
lesion. These conditions are the reverse of what happens in con- 
jugate lateral deviation due to lesions in the pons (p. 462), and 
we are thus enabled to differentiate between lesions in the two 
positions. 

There are four possible cases : 



Cerebral Lesions 
Pontine Lesions 

39 



Destructive. Eyes turned away from paralyzed side. 

Irritative. " " towards convulsed side. 

Destructive. " " towards paralytic side. 

Irritative. " " away from convulsive side. 



466 DISEASES OF THE EYE. 

The cerebral cases show that the center for associated movements 
is on the opposite side of the brain — e. g., in movements of eyes 
to the left, the left external rectus and right internal rectus are 
innervated by the right hemisphere of the brain; consequently, a 
destructive lesion here would produce paralysis of the left side 
of the body and of the associated movements of the above orbital 
muscles, and therefore the eyes would be drawn to the right by 
their opponents — i. e., away from the paralyzed side. A de- 
structive lesion of the right side of the pons would also, of course, 
produce paralysis of the left side of the body ; but, involving the 
right sixth nucleus, it would cause paralysis of the associated 
movements of the right external rectus and left internal rectus, 
and, consequently, the eyes would be drawn to the left by the 
opponents — i, e., towards the paralyzed side. 

The reverse of the foregoing would occur in irritative lesions. 
Fig. 146 serves to illustrate the points referred to. 

A destructive lesion at 12, the right cortical center, involving 
also motor centers of the body, would cause left hemiplegia ; and 
since the external rectus of the left eye and internal rectus of the 
right eye would be paralyzed, the antagonists would turn the eyes 
to the right — i. e., away from the paralyzed side. A destructive 
lesion of the right side of the pons, also producing left hemiplegia, 
if it involve the sixth nucleus, will produce paralysis of the ex- 
ternal rectus of the right eye and of the internal rectus of the left 
eye, and the antagonists would turn the eyes to the left — i. e., 
towards the paralyzed side. It is easy to see how irritative lesions 
would produce exactly the opposite effects. 

Hemianopsia interferes to a certain extent with the conjugate 
movement towards the affected side, in so far as this is guided by 
visual impressfons. According to Knies, the difficulty in read- 
ing the right hemianopsia is mainly due to this cause. 

It seems important here, even at the risk of some repetition, to 
direct special attention to 

The Localizing Value of Paralyses of Orbital Muscles in 
Cerebral Disease. — Paralysis of the Third Nerve. — As regards 
this nerve we are struck with the fact that ptosis, partial or com- 
plete, may be present as a focal symptom in cortical lesions — 
cerebral ptosis, as it is called — without any other third-nerve 
branch being paralyzed. That a separate cortical center for this 
branch of the third nerve exists, and that it innervates the muscle 
of the opposite side, is very probable. The existence of such a 



THE ORBITAL MUSCLES. 467 

centef would not be inconsistent with the view that, as regards the 
motions of the eyeballs, associated centers alone are present, for, 
although as a rule the elevators of the lids are associated in their 
motions, yet by an effort of the will most people can throw one of 
them into motion separately, or more than the other. No doubt 
the power to voluntarily innervate one levator and orbicularis 
alone varies in different individuals, and m many persons the 
levator centers are practically associated centers, and probably this 
is the reason why cerebral ptosis is rather rare. The position of 
this center is still an open question, but it is believed to be situated 
m front of the upper extremity of the ascending frontal convolu- 
tion close to the arm center. 

Ptosis, then, has no value as indicating the locality of a lesion 
in the cortex; but it may be of use in distinguishing a cortical 
lesion from one situated elsewhere in the brain, for monolateral 
ptosis, as the only focal symptom, occurs with cortical lesions 
alone. 

It is probable that ptosis, as the result of a cortical lesion, is 
a distant symptom in not a few of the cases where it is present. 

Ptosis on the side of the lesion has occasionally formed a 
symptom in disease of the pons without paralysis of the other 
branches of the third nerve — except, sometimes, in so far as con- 
jugate deviation (vide supra) is concerned — and without the third 
nerve being involved in the lesion. 

Again, ptosis, by forming a factor of a crossed paralysis, may 
serve to localize a lesion in the crus cerebri. When the third 
nerve is paralyzed by a lesion in this situation it is the rule to 
find it paralyzed as a whole, but paralysis of only some of the 
third-nerve branches may be produced by a lesion of the cerebral 
peduncle, and the branch to the levator palpebrse seems to be the 
one most frequently implicated alone. 

In order now to complete this subject of ptosis as a focal 
symptom I must refer to a rare form of it which has been de- 
scribed by Nothnagel, and which does not depend on a lesion of 
the third nerve. It may be called sympathetic or pseudo-ptosis, 
and is accompanied by other eye-symptoms, as well as by symp- 
toms of vasomotor paralysis of one side of the body, such as 
elevation of temperature, and redness and edema of the skin. In 
these cases, this author says, there is (i) apparent ptosis on the 
paralyzed side, owing to the contraction of the palpebral aper- 
ture, but the lid can be raised; (2) contraction of the pupil on 



468 DISEASES OF THE EYE. 

the same side; (3) a shrinking back of the eyeball into the orbit, 
so that it seems to have become smaller; (4) an abnormal secre- 
tion of thin mucus from the corresponding nostril, of tears from 
the affected eye, and of saliva from the corresponding side of the 
mouth. Nothnagel states he has found this train of symptoms 
in lesions of the corpus striatum. 

A common sign of disease of the crus cerebri is what is known 
as crossed hemiplegia. Paralysis of the third nerve on the side 
of the lesion, with hemiplegia, hemianesthesia, often facial, and 
sometimes hypoglossal, paralysis of the opposite side of the body 
is a frequent form of it. The lesion may implicate all the 
branches of the third nerve or only some of them. But the local- 
izing value of crossed hemiplegia, as Hughlings Jackson long ago 
pointed out, depends chiefly on the hemiplegia and paralysis of 
the cranial nerve coming on simultaneously. If they occur at 
different times they may be due to two distinct lesions, neither of 
which may be in the crus ; for the hemiplegia might be due to a 
lesion in the hemisphere, and the third-nerve paralysis to a basal 
lesion of earlier or later date. Yet a few cases have been ob- 
served where, with a lesion in the cerebral peduncle, the third- 
nerve paralysis preceded the hemiplegia by a considerable interval. 

That basal lesions are by far the most frequent cause of paral- 
ysis of the third nerve is beyond a doubt; and here it is usual, 
but not constant, to find it paralyzed in all its branches. The 
diagnosis to be made, when direct symptoms are being considered, 
is, for the most part, between a lesion in the crus and a lesion 
at the base. We cannot pretend to be able to make this diag- 
nosis with certainty in all cases. Complete paralysis of every 
branch of the third nerve without any other paralysis is almost 
always basal; so also are those cases in which, where there is 
hemiplegia, it is slight as compared with the degree of the third- 
nerve paralysis ; and those cases, too, to which I have already re- 
ferred, where there is an interval between the onset of the paral- 
ysis of the extremities and of the third nerve, are apt to be basal. 
Of course there may be such a combination of paralyses of the 
other cerebral nerves with that of the third nerve as to leave no 
doubt with reference to the basal position of the lesion. 

The third nerve may be paralyzed by lesions in the inter- 
peduncular space, in which case the paralysis may be partial 
(ptosis alone, or abolition of upward and downward motion 
alone), complete^ monocular, or binocular. When both nerves 



THE ORBITAL MUSCLES. 469 

are afifected there is generally also paralysis of the other orbital 
nerves, or of the facial nerve; and hemiplegia or hemianopsia 
may also be present. 

Thrombosis of the Cavernous Sinus invariably produces paral- 
ysis of the third nerve; but all the orbital nerves, as v^^ell as the 
fifth and the optic nerve, m.ay also be involved, giving rise to 
complete immobility of the eye, with loss of conjunctival and 
corneal sensation. . The pupil is usually contracted at first, but 
later on dilates. The venous obstruction causes exophthalmos, 
edema of the lids, and chemosis. Congestion papilla is some- 
times found. The general symptoms are rigors, high tem.pera- 
ture, and vomiting. Its principal causes are infective inflam- 
mation of the orbital cavity; erysipelas of the face; infective in- 
flammation m the buccal, nasal, and pharyngeal cavities, and of 
the body of the sphenoid; and extension of thrombosis of the 
sinuses from purulent otitis. The thrombosis in more than half 
the cases spreads to the other side through the circular sinus. 
When the invasion occurs from the intracranial direction, pain in 
some or all of the branches of the first division of the fifth nerve 
IS usually an early symptom. 

Third-nerve symptoms — in addition to those mcluded under 
the headings conjugate deviation, or paralysis, and ptosis — are 
sometimes distant symptoms. Tumors of the cerebral hemi- 
spheres, more particularly if accompanied by violent general head 
symptoms, indicating probably high intracranial pressure, are 
the lesions most apt to produce these distant third-nerve symptoms. 
As a rule the slighter the general cerebral symptoms, the more 
likely are the third-nerve paralyses to be direct symptoms. This 
rule, indeed, applies to other as w^ell as to third-nerve focal 
symptoms. 

Paralysis of the Fourth Nerve, when combined with paralysis 
of other motor eye-nerves, is difficult to recognize ; and conse- 
quently in such cases it supplies but little aid for localization. 
Solitary paralysis of this nerve as a symptom of cerebral focal 
lesion is extremely rare. Nieden has placed a case on record in 
which paralysis of one-fourth nerve was the only focal symptom 
to which a tumor of the pineal gland, of the size of a walnut, 
gave rise. But the isolated fourth-nerve paralysis is more apt 
to be produced by a basal lesion. Pfungen has pointed out that, 
in meningitis, exudation in the space between the corpora quad- 
rigemina and the splenium of the corpus callosum may implicate 



470 DISEASES OF THE EYE. 

the fourth nerves in the valve of Vieussens, and believes it is 
prone to do so in tubercular meningitis. In combination with 
paralysis of the third nerve it speaks for a lesion in the cerebral 
peduncle, extending- back to the valve of Vieussens, and was, I 
believe, utilized clinically by Meynert in this sense. 

When Paralysis of the Sixth Nerve occurs as the only focal 
sign it is probably due to disease at the base, or it is a distant 
symptom. There is no cranial nerve so liable to provide a distant 
symptom as the sixth. Gowers refers this liability to the 
lengthened course these nerves take over the most prominent part 
of the pons, which renders them readily affected by distant pres- 
sure. One or both nerves may in this way be paralyzed. Wer- 
nicke states that sixth-nerve paralysis is most apt to be present 
as a distant symptom when the lesion, especially a tumor, is 
situated in the cerebellum, differing in this way from the third 
nerve, which, as I have said, is more likely to give distant symp- 
toms with a lesion in the cerebral hemisphere. 

Paralysis of the sixth nerve, simultaneous m its onset with 
hemiplegia of the opposite side of the body, indicates a lesion 
in the pons, usually a hemorrhage, on the side corresponding to 
the paralyzed nerve. We know that the fifth and facial, and 
sometimes the auditory, spinal accessory, and hypoglossal nerve, 
may all, in varying combinations, form one of the elements in a 
crossed paralysis from a lesion in this position ; but, if special 
localizing value is to be given here to the participation of any 
one cranial nerve, that nerve is the sixth. The paralysis of this 
nerve, simultaneously with palsy of the opposite side of the body, 
while other conditions point to an intracranial lesion, speaks, then, 
almost certainly for pontine disease. 

Basal paralysis of the sixth nerve is frequently double, espe- 
cially in syphilis. Fracture of the apex of the petrous portion of 
the temporal may also cause it. 

Paralysis of the facial with the sixth is not an uncommon com- 
bination caused by a lesion in the pons, which at the same time 
produces hemiplegia of the opposite side of the body. This com- 
bination is a natural one, in view of the close relations of the 
nuclei of the sixth and seventh nerves. Indeed, according to 
Lockhart Clarke, Meynert, and others there is one nucleus which 
is common to both nerves — a view not shared in by Gowers and 
others. The manner in which the root of the facial nerve winds 
round the sixth-nerve nucleus must also have an important bear- 



THE ORBITAL MUSCLES. 471 

ing on the occurrence of associated paralyses of these nerves. 
(See also p. 207.) 

Hemiplegia due to a lesion of the cortical motor region, which 
might happen to be combined with paralysis of the sixth nerve 
as a distant symptom, ofifers no difficulty in its diagnosis from 
hemiplegia with sixth-nerve paralysis in pontine disease ; for, 
while the latter is a crossed paralysis, the former is homonymous. 

Paralysis of the Seventh Nerve. — When lagophthalmos occurs 
as a symptom in focal cerebral disease, it is useful in localizing 
the disease by assisting in differentiating a lesion in the internal 
capsule, or in the facial motor center of the cortex, from one im- 
plicating the portio dura in the pons, as it is absent, or very slight, 
in the former cases, but very often markedly present in the latter. 
With a lesion in the lower part of the pons we are apt to have 
lagophthalmos with crossed hemiplegia ; but if the lesion be in the 
upper part of the pons — the fibers from the opposite side having 
here joined the motor tract — the hemiplegia and lagophthalmos 
will be homonymous. 

Paralysis of the Fifth Nerve, with hemiplegia of the opposite 
side, points to disease in the pons. Neuroparalytic ophthalmia 
is said to be the rule in basal lesions of the fifth nerve, and to 
occur very rarely in nuclear or fascicular lesions. 

The Orbicular Sign may be noticed in some attacks of apoplexy 
with hemiplegia after consciousness has returned. It consists 
in this, that the hemiplegic person, who during health has been 
able to close each eye separately, and who even now can close both 
eyes together, or the eye on the sound side alone, is unable to close 
the eye on the paralyzed side by itself. This sign usually passes 
away after a short time. Sometimes when both eyes are closed 
it requires a greater effort to bring the eyelids together on the 
paralyzed side. I saw the orbicular sign very well marked and 
persistent in an obscure case of Dr. Wallace Beatty's where a 
gross cerebral lesion was suspected. 

Extensive basal lesions, especially the syphilitic, may pro- 
duce symptoms due to involvement of widely separate structures, 
without interfering with those which intervene ; hence they tend to 
implicate several nerves without reference to system or function. 

Convergent Concomitant Strabismus. — This is the condition 
which is popularly known as inward " cast " or " squint." It 
makes its appearance in children, when they begin to take an in- 
terest in small objects, such as toys and pictures ; or a little later, 



472 DISEASES OF THE EYE 

when the first lessons are learned — in short, when they begin to 
make frequent and prolonged demands on their internal recti and 
accommodation, most commonly from the age of three to six 
years. 

The term '^ concomitant " {concomitaHis, accompanied) is given 
to it in contradistinction to " paralytic " strabismus ; because in it 
the squinting eye, by virtue of the normal innervation of the as- 
sociated muscles, accompanies the straight one in all its move- 
ments to an equal extent. At the primary position of the eyeballs, 
in a case of concomitant squint, the parallelism of the visual axes 
is defective, and, as the eyes are moved from side to side, the 
defective parallelism continues in the same degree, neither in- 
creasing nor decreasing. Moreover, if the straight eye be shaded 
by the surgeon's left hand, and the squinting eye by this means 
be obliged to fix the object of vision — e. g., the tip of the index 
finger of the surgeon's right hand held up two or more feet dis- 
tant in the medim line — it will be found that the straight eye is 
now squinting inwards. This deviation of the straight eye is 
called the secondary deviation, and, m these cases of con- 
comitant strabismus, it is equal in degree to the primary devia- 
tion of the squinting eye ; because the internal rectus of the 
good eye, being associated in its action with the external rectus 
of the squinting eye, when the latter muscle is forced, in the fore- 
going experiment, to roll its eye outwards in order to bring it to 
fixation, the internal rectus of the good eye, receiving a similar 
nervous impulse, rolls that eye inwards to the same extent as the 
squinting eye has been rolled outwards ; and the good eye 
will therefore present, under the covering hand, an internal stra- 
bismus of the same amount as that which had previously been 
present in the squinting eye. This is an important point, for it is 
an aid in the differential diagnosis of this form of strabismus from 
the paralytic form, in which the secondary deviation is greater 
than the primary one (see General Principle No. 2, p. 448). 

In order to decide which is the squinting eye it is merely neces- 
sary to direct the patient to look at an object held up in the 
median line on a level with his eyes, and a few feet in front of 
him. 

In concomitant strabismus, of course, both eyes never squint 
simultaneously, as one hears it sometimes stated by parents. 

Causes. — Squint is never due, as is popularly supposed, to 
fright, imitation, or naughtiness; nor is it ever brought on by 



THE ORBITAL MUSCLES. 473 

the patient looking at a lock of hair, or other object, which may 
happen to hang very much to one side. 

Bonders pointed out that in a large proportion of cases of 
convergent strabismus the refraction is hypermetropic, and he 
drew the conclusion that hypermetropia is to be regarded as the 
cause of the strabismus in the following way: It has been 
shown (chap. i. p. 22) that with each degree of normal con- 
vergence of the optic axes a certain effort of accommodation is 
associated. The greater the angle of normal convergence the 
greater is the possible effort of accommodation. 

Of this physiological fact, Bonders said, the hypermetrope often 
unconsciously takes advantage, and, in order to brace up his ac- 




FiG. I47i 

commodation in an excessive degree for the sake of distinct vision 
with one eye, he increases the angle of convergence of the 
optic axes by rotating the other eye (L, Fig. 147) somewhat in- 
wards. The angle /' is thus made larger than the angle /, and 
the effort of accommodation normally belonging to the angle /' 
is obtained for the eye R, which consequently receives a clearer 
image of the visual object A on its retina. But, inasmuch as all 
hypermetropes do not squint. Bonders considered that there were 
contributing circumstances, which caused each hypermetrope to 
unconsciously decide between distinct monocular vision with 
strabismus, and indistinct binocular vision. The latter, he said, is 
likely to be preferred if the condition pf the refractipn and the 
40 



474 DISEASES OF THE EYE. 

acuteness of vision is the same in each eye; while, if the retinal 
images differ much, by reason of one eye being more ametropic 
than its fellow, from nebulous cornea, or from other causes, the 
desire for binocular vision would be less strong, and the imper- 
fect eye would deviate inwards for the sake of the resulting in- 
crease of accommodation in the perfect eye. 

It is admitted on all hands that hypermetropia is one of the 
causes of internal strabismus, but, as Schweigger ^ has pointed 
out, it is not the only cause, and probably not even the principal 
cause, for the following reasons : ( i ) If Bonders' theory be com- 
plete, convergent strabismus must always appear, whenever there 
is binocular hypermetropia, along with the conditions which re- 
duce the value of binocular vision. But strabismus is often ab- 
sent, while the degree of ametropia is markedly different in the 
two eyes, or while the acuteness of vision is very defective in one 
eye. (2) According to Bonders' theory, the higher the degree of 
the hypermetropia the greater should be the tendency to strabis- 
mus ; and yet clinical observation shows that this is not the case. 
(3) In periodical strabismus, the influence of hypermetropia 
and of the accommodative effort is very evident; and yet 
these cases only go to show that, while hypermetropia is 
very frequently one of the causes of strabismus, it is not the 
only or most important one ; for here, clearly, some factor neces- 
sary for the production of a permanent squint is wanting. (4) 
Bonders' theory fails to explain the occurrence of convergent 
strabismus in emmetropic and in myopic individuals, where, of 
course, no excessive effort of accommodation is required. 

Schweigger considers that a want of equilibrium between the 
muscles is the chief cause of strabismus (divergent as well as 
convergent), and that convergent strabismus is mainly due to a 
preponderance in the power of the internal over the external recti ; 
or, with equal accuracy one might say, to an insufficiency of the 
external recti. It would seem that in hypermetropia the ex- 
ternal recti are apt to be congenitally less powerful than the 
internal recti ; while in myopia congenital insufficiency of the in- 
ternal recti is the more common condition. The internal recti 
do, however, sometimes preponderate in emmetropia, and even in 
myopia ; and convergent strabismus does sometimes occur in 
these forms of refraction. Whatever be the condition of refrac- 
tion, strabismus is more apt to be developed if the value of 
binocular vision be diminished by imperfect sight in one eye. 



THE ORBITAL MUSCLES. 475 

Schweigger does not, however, give any proofs of this preponder- 
ance of certain muscles. 

Spontaneous cure of strabismus sometimes takes place, most 
commonly between the tenth and sixteenth year of age. That 
it may happen with hypermetropia, and with defective vision in 
one eye, is strongly against Bonders' theory. 

According to Hansen Grut's view,^ convergent squint originates 
in, and is maintained as the result of, an innervation which induces 
in the interni a shortening greater in amount than that which is 
desirable. 

Single Vision in Concomitant Convergent Strabismus. — For 
the most part these patients do not complain of double vision, 
although diplopia is the rule in cases of convergent strabismus 
due to paralysis of the external rectus, ^^lly is this? The im- 
age of the object looked at, it will correctly be said, must be 
formed in the squinting eye in each of these kinds of strabismus, 
on a part of the retina not identical with that in the fixing eye, 
but lying to the inside of it; and hence the image of the object 
should be projected by the squinting eye to its own side of the 
true position of the object (homonymous diplopia), and the lat- 
ter should therefore be seen doubled. It is seen doubled in the 
paralytic form ; why not also in the concomitant form ? The only 
explanation of this circumstance, which, until within the last few 
years, had been put forward, was, that convergent concomitant 
strabismus being a quasi-physiological condition, the patient's 
mind involuntarily suppresses the annoying image belonging to the 
squinting eye in a manner analogous to that by w^hich, when we are 
deeply interested in conversation, all extraneous sounds are un- 
perceived, although they, too, must reach the nerve of hear- 
ing. This suppression of the image belonging to the squint- 
ing eye w^as believed to be the more easy owing to the in- 
distinctness of the image itself, formed as it is on a per- 
ipheral part of the retina, while in the good eye it falls on 
the macula lutea. We often find, moreover, that the squint- 
ing eye is ab initio more defective (macula cornea, higher de- 
gree of hypermetropia, astigmatism, etc.) than its fellow, and it 
w'as held that this, too, rendered suppression of its image more 
easy. Such a suppression of the image is possible, and it no 
doubt does occur in many cases of strabismus; but it is certain. 
as pointed out by Schweigger, that it does not occur in all of them, 
perhaps not even in most of them. It would be beyond the 



476 DISEASES OF THE EYE. 

scope of this handbook were I to go into the arguments on this 
point. Suffice it to say that, in those cases where suppression 
of the image of the squinting eye does not take place, a certain 
participation in the act of vision on the part of this eye, when 
not too bUnd, is impUed. One of two events takes place in those 
cases : Either the region of the retina, on which, in the squinting 
eye, the image of the visual object is formed, becomes functionally 
developed into a spot to a great extent physiologically *' identi- 
cal " with the macula lutea of the straight eye, and then some- 
thing approaching normal binocular fusion of the images comes 
about, and hence single vision; or else diplopia is actually pres- 
ent, although, as a rule, it passes unnoticed by the patient, owing 
to its having become habitual to him. In some cases the first 
of these conditions is the actual state, in others it is the second 
which exists. I shall mention one fact in support of each, but 
must refrain from entering more deeply into the subject. In 
support of the first is the occurrence, not rarely observed, of 
crossed diplopia after operation for concomitant convergent stra- 
bismus, even when there is no divergence produced ; and in sup- 
port of the second, the diplopia which intelligent patients often 
admit, when they are carefully examined with the aid of a red 
glass before the good eye. 

Amblyopia of the Squinting Eye. — In a large proportion of 
the cases of internal concomitant strabismus the squinting eye — 
even where there is no marked astigmatism, and where the media 
are clear — is amblyopic. Schweigger states the proportion of 
these amblyopic cases to be 30 per cent., but I believe the per- 
centage to be much larger. It has been a very generally ac- 
cepted opinion that this amblyopia is due to want of use on the 
part of the squinting eye, in consequence of the suppression 
of the image on its retina, and hence it is termed amblyopia ex 
anopsia. If this view were the correct one, we ought always to 
find only slight amblyopia of the squinting eye in children soon 
after strabismus comes on ; while it should be of high degree — 
in fact, the eye should be almost useless — in adults who have not 
been operated on, and in whom monolateral strabismus had been 
present since childhood. And yet marked amblyopia may often 
be found in children in the squinting eye, while in adults the 
squinting eye often has very good vision — in short, the amblyopia 
of the squinting eye is not progressive, as it would be were it ex 
anopsia. 



THE ORBITAL MUSCLES. 477 

Again, many squinting eyes, when the straight eye is 
covered, instead of fixing the visual object with the macula 
lutea, remain unchanged in position, or even turn inwards more 
than before (amblyopia with eccentric fixation) ; and in less 
well-marked cases of the same sort, although there is no ec- 
centric fixation, yet the preference for fixation with the macula 
lutea is lost, and uncertainty of fixation results, no one part 
of the retina being more useful for that purpose than another. 
It is held by many that this form is characteristic of amblyopia 
ex anopsia, and is the result of the strabismus ; but it is identical 
with a form of congenital amblyopia often present in only one 
eye without strabismus. A strong argument in favor of ambly- 
opia ex anopsia is the improvement which often seems to take 
place in the vision of the squinting eye by systematic separate 
use, or after the strabotomy. But, it is tolerably certain that, 
where the improvement takes place, the defective vision has 
been due rather to retinal asthenopia than to amblyopia; and 
if, at the outset, patients be pressed to discern the test-types, 
they often succeed in producing a better acuteness of vision than 
they at first seemed to possess. In many cases separate use fails 
altogether in improving the vision of the squinting eye, even when 
it is not very defective — a fact which is unfavorable to the am- 
blyopia ex anopsia theory. The circumstance that in alternating 
strabismus the sight of each eye is good, cannot be regarded as 
proof in favor of amblyopia ex anopsia. I myself strongly in- 
cline to the views so ably put forward by Schweigger. The ex- 
planation which he gives of the very frequent presence of am- 
blyopia in the squinting eye is that it is congenital ; and, far from 
being the result of the strabismus, is a factor in its produc- 
tion, just as opacities of the cornea, or high degrees of ametropia, 
have always been admitted to be. 

Priestley Smith '^ holds somewhat different opinions. To ac- 
count for the phenomena of convergent strabismus, we have, 
he says, to consider the natural conditions of vision in early 
childhood. An infant's vision at birth is a mere perception of 
light, and his eye-movements are involuntary and purposeless. 
As the organs develop he learns to control these movements, to 
direct his eyes simultaneously to a given point, to fuse the two 
retinal pictures in one mental impression, and to recognize the 
forms of objects. During the first few years of life these newly 
acquired faculties are less stable than later on, and more easily 



478 DISEASES OF THE EYE. 

disturbed. Hence the greater liability to strabismus in infancy. 
Among three hundred and forty-seven cases where the onset age 
was ascertained, two hundred and fifty-four, = 73 per cent., be- 
gan before the children were five years old. Three years old 
was the commonest age. 

The hypermetropic child is specially liable to convergent strabis- 
mus because he has to overcome a special difficulty; he must 
learn to converge normally, while he accommodates abnormally. 
Failing in this, he squints in order to see clearly. Many squints 
arise in this way. But Priestley Smith says the influence of hy- 
permetropia must not be exaggerated ; most young children are 
more or less hypermetropic ; the vast majority of hypermetropes of 
all degrees and all ages have no squint, and some squinters have 
little or no hypermetropia. 

Infantile disorders — convulsions, whooping-cough, measles, a 
fright, a fall, etc. — are often the starting-point of strabismus, be- 
cause the controlling influence of the higher brain centers is 
weakened at such times. 

Priestley Smith thinks that a contmuous squint involves weak- 
ening or loss of visual function, and that the younger the child 
the more readily does this occur. The sense of fusion, being 
no longer exercised, is gradually lost, and may prove irrecover- 
able a few years later, even though the eyes be put straight. 
Further, an eye which never fixes the object at which the patient 
looks, loses the power of true fixation. Such loss is found most 
often amongst cases of early onset and long duration ; it is 
rarely, if ever, found until the squint has become continuous for 
at least six months. Again, it is probable that the early onset of 
strabismus, with complete disuse of the squinting eye, may ar- 
rest the development of form-perception in the latter, and thus 
render it permanently amblyopic. 

We should, therefore, he thinks, treat strabismus as early as 
possible, to prevent secondary impairment of vision, or to correct 
such impairment by educative measures, if it be already present. 
By covering the good eye with a pad (almost always possible, with 
patience on the mother's part) we can oblige the child to use the 
neglected eye. We can thus preserve its function intact, or 
stimulate it if it be already weakened. We can even restore fixa- 
tion-power to an eye which has already lost it, if the loss be not 
of too long standing. Spectacles to correct refractive errors, if 
required, are used in conjunction with the pad. At later ages 



THE ORBITAL MUSCLES. 



479 



" bar-reading " and the stereoscope will aid in the recovery of 
binocular vision. 

It is often right, Priestley Smith considers, to operate even at 
very early ages, when persistent use of the spectacles and 
pad gives no continuous improvement. To postpone operation 
in all cases to five or six years of age is often, he thinks, to lessen 
the likelihood of a complete cure. 

There are Three Clinical Varieties of Convergent Concomitant 
Strabismus. — (i) Periodic. (2) Permanent alternating. (3) 




Permanent monolateral. Periodic strabismus occurs only when 
some great effort of accommodation is required. It sometimes is 
the first stage of permanent monolateral or of alternating stra- 
bismus; but these two latter forms do not always have their be- 
ginning in the periodic form, which often continues as periodic 
to the end of the chapter. In alternating strabismus the patient 
squints sometimes with one eye and sometimes with the other. 



48o DISEASES OF THE EYE. 

In permanent monolateral strabismus the squint is confined to one 
eye. 

Measurement of Convergent Strabismus. — The amount or de- 
gree of the deviation of the squinting eye from its normal posi- 
tion is not the same in every case, and the size of the squint is 
measured by one of the following methods. Whichever of them 
be used, it is important that the patient be directed, during the 
test, to regard a distant object placed in the median line and on 
a level with his eyes. If he look at a near object the squint may 
be overestimated, by reason of its increase with accommodation. 

I. By the Linear Method we measure the number of milli- 
meters by which the eye deviates from its normal position. The 
good eye is shaded, and the squinting eye is caused to fix an ob- 
ject in the median line — by preference a distant object. Close 
under the margin of the lid a strabometer (Fig. 148) is then 
placed, so that the o point may coincide with a perpendicular let 
fall from the center of the cornea. The shade being removed 




Fig. 149. 

from the good eye, the squinting eye is allowed to resume its ab- 
normal position, and the degrees recorded on the instrument, un- 
der a perpendicular let fall from the center of the cornea in this 
position, are read off. They give the amount of the deviation. 
2. Hirschberg's Method ^ consists in estimating the degree of 
deviation by the position of the corneal reflex of a candle flame 
held straight in front of, and about a foot from, the eye. Where 
there is no squint this reflex is situated at, or (with large angle y) 
slightly to the inner side of, the center of the pupil in each eye. 
In a convergent squinting eye it is displaced outwards, and 
Hirschberg recognizes five groups of strabismus. Group i (Fig. 
149 representing the right eye), in which the reflex is nearer 
to the center than to the margin of the pupil. This represents a 



THE ORBITAL MUSCLES. 



481 



strabismus of less than 10°, and no operation is indicated. Group 
2, in which the reflex is at or about the margin of the pupil, repre- 
senting a strabismus of 12° to 15°, and indicating a simple ten- 
otomy with occasionally a tenotomy of the other int. rectus. 
Group 3, in which the reflex is outside the pupillary mar- 
gin, about halfway between the center of the pupil and the 
corneal margin. This represents a strabismus of about 25°, 
and indicates a tenotomy of the internal rectus, com- 



BO 



Fig. 150. 




bined with a moderate advancement of the external rectus. 
Occasionally, later on, a tenotomy of the other internal rectus 
will be required. Group 4, in which the reflex is on or near the 
corneal margin ; representing a strabismus of 45° to 50°, and in- 
dicating a tenotomy of the internal rectus, along with energetic 



482 DISEASES OF THE EYE. 

advancement of the external rectus, and sometimes a later tenot- 
omy of the other internal rectus. Group 5, in which the reflex 
is on the sclerotic, between the margin of the cornea and the 
equator bulbi. This represents a strabismus of 60° to 80°, and 
requires the combined operation, with strongest possible advance- 
ment of the externus. Even this is sometimes insufficient, and a 
tenotomy of the internal rectus, or even the combined operation 
on the other eye, may be subsequently required. This is a 
modification of the linear method, and is a convenient one in 
routine practice. 

3. Priestley Smith measures strabismus by means of a double 
tape (Fig. 150), used in conjunction with the ophthalmoscope, 
as shown in the accompanying figures. The patient places the 
ring P on one of his fingers, and holds it to his cheek. The 
observer places the ring O on the forefinger of the hand which 
holds the ophthalmoscope; this keeps his eye at a distance or 
one meter from the patient's face. He uses his disengaged hand 
as a fixation object for the patient, holding it edgewise towards 
the patient, and letting the graduated tape slide between his 
fingers. A small weight at the end of the tape keeps it stretched 
as the hand moves in either direction. 

Fig. 151 illustrates the measurement of a convergent strabismus 
of the right eye. The patient, seated below the lamp and hold- 
ing the tape as above described, is told to look at the mirror. 
The observer, holding the ring and the mirror in the right 
hand, throws the light on the patient's left eye (L) — i. e., the 
fixing eye. He sees the corneal reflex in the center of the pupil, 
and knows thereby that this eye is fixing properly. He then 
throws the light on the right eye {R), and sees the reflex situated 
eccentrically outwards, and knows that this eye deviates inwards. 
Taking the graduated tape between the fingers of his left hand, 
and telling the patient to watch this hand, he moves it outwards 
along the tape (see Fig. 150), and meanwhile watches the corneal 
reflex in the deviating eye. When this latter reaches the middle 
of the pupil he reads the position of the hand upon the tape. The 
axis of the deviating eye {R) has moved from R' io O, through 
the angle R' R O. The axis of the non-deviating eye (L) has 
moved through an equal angle (0 L L'). The angular move- 
ment of L, as measured by the tape, equals the angular deviation 
oi R. 

Fig. 152 illustrates the measurement of a divergent strabismus 



THE ORBITAL MUSCLES. 



483 



of the right eye. The hands must be reversed, but the principle 
is the same as before. 

The graduated tape is a substitute for a graduated arc of a 
circle, but does not exactly correspond with such an arc; the 
error involved is, however, so small as to be of no importance 
if the observer keep his two hands at about the same distance 
from the patient's face. In this mode of measuring a strabismus 
it is the excursion of the fixing e}-e which is actually measured, 
and the excursion of the deviating eye is supposed to be equal to it. 
If the excursions of the two eyes are unequal, the result would 




be at fault. The method, though difficult to explain in words, 
is very quick and satisfactory' in practice. 

4. The Angular ^lethod. — The object aimed at here is to de- 
termine the size of the angle, which the visual axis of the squint- 
ing eye makes, with the direction it should normally have. For 
this purpose a perimeter is employed. Let us suppose that the 
right eye (R, Fig. 153) be the squinting eye, and that P P 
be the arc of the perimeter. The patient is placed at the instru- 
ment, as though the field of vision of his squinting eye were about 



484 DISEASES OF THE EYE. 

to be examined. He is directed to look at a distant object (A) 
with his good eye (L). The visual line from R should now- 
pass through the point 0, but it passes through the point n, 
and therefore R n is the angle of the strabismus. The surgeon 
finds the position of n by carrying the flame of a candle along the 
perimeter, until, with his eye placed behind the flame, he finds 
that the corneal image of the flame occupies the center of the 
pupil. The flame itself will then be at n, and the size of the 
squint-angle may be read off there. This gives us the optical 
axis of the eye; but, to be strictly accurate, we must remember 
that the position of the visual axis is what we require, and 
that it lies a few degrees farther inwards, according to the size 
of the angle y. The angular method is now in general use in- 
stead of the linear method, than which it is more accurate. 

5. A good subjective method for determining the dimension 
of a strabismus, but which can only be used where diplopia is 
present, is what may be called the Method by Tangents. Upon a 
wall of the consulting-room, in a horizontal line, and so as 
to be on a level with the eyes of the patient who is placed about 
3 meters from the wall, are, permanently marked out, tangents of 
angles of 5° each, as seen from the place where the squinting eye 
is. Exactly opposite to the squinting eye is 0°, while towards the 
right and left the points are marked up to 45° or more. The 
flame of a candle being held at 0°, and one eye of the patient being 
covered with a red glass, he is called on to indicate the position 
of the image belonging to the squinting eye, and the number on 
the wall which corresponds to this gives the angle of the stra- 
bismus. For the purpose of estimating paralyses of the orbital 
muscles, a similar row of tangents, or several such, may be 
marked out in the vertical direction. 

Mobility of the Eye Outwards in Convergent Concomitant 
Strabismus. — This is often defective in the squinting eye, and 
sometimes also in the fixing eye. The excursiveness of the 
lateral motions of the eyeball may be measured by the perim- 
eter. Having placed the patient as though the field of vision, 
say of his right eye, were about to be examined, he is di- 
rected to follow with his eye the flame of a candle carried along 
the perimeter from 0° towards 90° in the temporal direction ; and 
when it is found that the eye cannot be turned any farther in this 
direction that extreme position is noted by the position of the 
candle at the perimeter. The corneal image of the flame must, of 



THE ORBITAL MUSCLES. 485 

course, be central when the position of the flame is read off. In a 
similar way the mobility of the eye inwards may be measured. In 
the normal eye the mobility in each direction is about 45°. In 
strabismus we simply compare the outward mobility of the squint- 
ing eye with that of the good eye, to ascertain how much, if any- 
thing, the former lacks of its normal amount. 

Treatment. — The bearing of hypermetropia on the production 
of many cases of strabismus long since suggested the idea of 
curing the deviation by spectacles, which would correct any 
existing hypermetropia. The accommodation having been par- 
alyzed by atropin, and kept under its influence for some weeks or 
months, spectacles which completely correct the hypermetropia 
and astigmatism are meantime constantly worn. Should the 
patient require to use his eyes for near work while under treat- 
ment, it is necessary that he should have suitably higher + 
glasses for his near work. Occasionally good cures are effected 
by this means, and even when atropin is not used ; and when a 
periodic strabismus in a child comes under my care I always think 
it worth while to attempt its correction in this way ; but in general 
it is, by itself, of no use whatever. 

Orthoptic Treatment. — To Javal ^ is due the credit of devising 
this method ; but although he did so some years ago it is only 
recently that the treatment has been introduced into practical oph- 
thalmology. 

In order that the treatment may be carried out it is neces- 
sary, in the first instance, that the strabismic person should 
have diplopia. If the latter be not present spontaneously it has 
to be developed ; and it is sometimes possible, when the sight in the 
squinting eye is not too defective, to give the patient diplopia — 
i. e., to make him continuously conscious of the presence of the 
image belonging to the squinting eye. This may be done by 
means of exercises with a prism, base downwards, before the 
deviated eye, and a candle flame as visual object. The exercises 
are to be repeated daily until diplopia without a prism is estab- 
lished. Javal recommends the following exercise to develop di- 
plopia : A screen — e. g., a large sheet of cardboard — is held ver- 
tically between the two eyes, while the patient is directed to look 
at a candle flame about 2 meters in front of him. Double vision 
may immediately appear ; but, if it does not, it may be brought out 
by now and then covering the good eye for a moment, or by 
placing before it a red glass^ which can soon be done without. 



486 DISEASES OF THE EYE. 

Less brilliant visual objects are gradually substituted, until, 
finally, the double vision will continue even when, at first cau- 
tiously, the screen is removed. 

Double vision having been established, we proceed to enable 
the patient to fuse the double images — i. e., to obtain binocular 
vision — and when we have succeeded in doing this we have cured 
the squint. The end in view is best effected by means of a 
stereoscope, into which, in place of the usual prisms, + 6 D lenses 
have been introduced. The focal distance of these lenses being 
about the length of an ordinary stereoscope, rays coming from the 
slides, and passing through them, fall into the observer's eye as 
parallel rays; the accommodation consequently is suspended, and 
under normal conditions the visual lines are parallel, as though 
looking at a distant object. In the normal state the double pic- 
ture, or diagram, will seem to be single, but to the strabismic pa- 
tient in whom diplopia is present it will be double. Our duty, 
then, is to diminish the distance between the pictures, until the 
patient finds himself just able to fuse the images into a single 
impression. After a day or two the distance is increased slightly, 
and so on, until, finally, the normal position is reached. It is 
needless to say that in these exercises all errors of refraction must 
be eliminated by the proper glasses.* Priestley Smith's fusion 

* The existence or otherwise of true binocular vision may be ascer- 
tained by the simple experiment of giving the patient a book to read, and 
holding a cedar pencil halfway between his eyes and the page at right 
angles to the lines of type. If binocular vision be present, the pencil 
will not offer any impediment to the reading ; but if it be not present, parts 
of the page will be hidden behind the pencil. The reader may prove this 
by performing the experiment on himself, first with both eyes open (bin- 
ocular vision), and then with one eye shut. 

Another method is that known as Hering's Drop Experiment. A 
cylinder about 25 cm. long, and wide enough to take in both eyes of a 
person, is provided — at the opposite end from that placed around the eyes 
— with two strong wires 18 inches long, which jut out in continuation, 
as it were, of the cylinder, but which are bent outwards sufficiently to 
keep them out of view of the patient. Between the ends of these wires 
a fine thread is stretched, with a small bead fastened at its middle point, 
so that the bead may occupy the center of the field when the patient looks 
through the cylinder. During the experiment the thread is in the hori- 
zontal position, and the bead is used as the patient's fixation point. Small 
balls of different sizes (peas, beans, etc.) are then let fall from a height, 
one after another, a couple of dozen times or more, some of them in 
front of the thread, some of them behind it. If the patient have normal 
binocular vision, he will be able to say each time with certainty whether 
the ball falls in front of or behind the thread; but if he have not true 



THE ORBITAL MUSCLES. 487 

tubes are also useful for bringing about fusion of the double 
images. 

The pictures used in the stereoscope should be geometrical 
figures, or especially designed pictures, in order that both sur- 
geon and patient may the more readily recognize their fusion. 

Only the very slight degrees of strabismus are adapted for the 
attempt at cure by orthoptic treatment. A marked deviation will 
not be amenable to it. Moreover, it makes demands both upon 
the patience and intelligence of the patient, which are rarely 
fulfilled, especially in hospital practice. A field more fertile in 
good results for the employment of this treatment is found in 
the completion of cures which have been commenced by operative 
measures. 

Operative Treatment. — Division of the tendon of the internal 
rectus muscle, combined, sometimes, with advancement of the 
insertion of the external rectus, is the measure which has to 
be applied in most of the cases which come under our notice. 
I am strongly opposed to operative interference in patients under 
five years of age, and very much prefer that they should be 
seven or eight years old, or even older. Early childhood offers 
a decided obstacle to the careful adjustment of the operation 
and to orthoptic treatment. 

In order that the operative proceeding may be adapted to 
each case, the following points must have been previously noted 
with care: (i) The dimension of the strabismus angle. (2) 
The lateral mobility of the eyes, especially the mobility out- 
wards of the squinting eye. (3) The refraction of the eyes, and 
the acuteness of vision of the squinting eye, as well as the pres- 
ence, or otherwise, of diplopia : the first in order that glasses for 
the correction of any hypermetropia may be worn, if desirable, 
after the operation ; the second, because, ceteris paribus, an opera- 
tion for convergent strabismus will produce a more marked effect 
if the vision in the squinting eye be good than if it be very de- 
fective ; and the third, because the presence of diplopia encourages 
the hope that binocular vision may be restored. 

Rules which will insure in every case, with absolute cer- 
tainty, the desired degree of operative effect cannot be laid down. 
The following will be found to answer in the majority of cases, 
and if the effect be now and then too great it can easily be ad- 
binocular vision, if only one eye be used, he will merely guess at the 
position of the falling ball, and will make frequent mistakes. 



488 DISEASES OF THE EYE. 

justed by bringing forward the internal rectus, or by set- 
ting back the external rectus, within a few days after the 
operation. In every instance it should be the desire of the 
surgeon to leave 2° or 3° of strabismus behind; for the effect 
of the operation is apt to increase within a year, and, if absolute 
parallelism be present at first, divergence may ultimately super- 
vene. The establishment of binocular vision when possible would 
do away with this remnant of strabismus ; but under any circum- 
stances the latter does not detract from the cosmetic result. 

If the vision of the squinting eye be fairly good, and the de- 
viation amount to not more than 15° or 20°, and the power of the 
external rectus be sufficient, the correction can be effected by the 
tenotomy of the internal rectus of the squinting eye. A strabis- 
mus of 20° will require the free separation of the delicate connec- 
tions between the anterior surface of the tendon, or capsule of 
Tenon, and the conjunctiva as far back as the caruncle, in order 
that the tendon may be free to contract. For a deviation of 15° 
or less this separation should not be so free, or should be quite 
omitted ; or, if a very slight effect be desired, it can be produced 
by drawing the conjunctival wound together, after an operation 
which has been confined strictly to the insertion of the tendon. 

If the vision of the squinting eye be fairly good, and the power 
of the external rectus sufficient, and if the squint be more than 
20°, it is advisable to divide the proceeding between the eyes — e. g., 
if it be 30°, about 20° are corrected by tenotomy of the internal 
rectus of the squinting eye, and the remainder by tenotomy of the 
internal rectus of the fixing eye. If desired, the effect of the 
tenotomy in one or both eyes may be increased by a suture passed 
through a fold of conjunctiva at the outer side of the globe, and 
tied tightly. 

If, although the vision of the squinting eye be good and the 
deviation not more than 20° or 25°, there be marked loss of 
power of the external rectus muscle, tenotomy of the internal rectus 
alone will often lead to disappointment, and a good result will 
require this tenotomy to be combined with advancement of the 
external rectus, the operative measures being confined to the 
squinting eye. But advancements in such cases as this must be 
very cautiously carried out, as an excessive effect may easily be 
produced. The external rectus should be but slightly brought 
forward. 

If the deviation exceeds 35°, even when there is good vision 



THE ORBITAL MUSCLES. 489 

in the squinting eye, and no loss of power in the external rectus, 
tenotomy of the internal rectus of each eye is rarely sufficient, 
and as a rule advancement of the external rectus of the squint- 
ing eye must be combined with these measures. 

With a deviation of 30° to 35°, and loss of power in the ex- 
ternal rectus, the demand for advancement of the external rectus 
becomes more imperative. The correction of squints of 40° and 
more are, in every instance, to be effected by tenotomy with 
vigorous advancement in the squinting eye, and subsequent ten- 
otomy of the internal rectus in the good eye. 

In cases where the vision of the squinting eye is much reduced, 
the deviation great, and the insufficiency of the external rectus 
marked, the combined operation in one or both eyes is the 
proper proceeding. 

Mode of Operating for Strabismus. Tenotomy. — The in- 
struments required for this operation are a spring-stop speculum, 
a small-toothed forceps, a blunt scissors somewhat curved on the 
flat, and two strabismus hooks (Fig. 154). 

The eye having been thoroughly cocainized, the patient is placed 
on his back, the surgeon standing in front of him and on his 
left-hand side if the left eye is to be operated on, or behind 
him if it be the right eye. The speculum is then applied, and 
the conjunctiva over the insertion of the tendon of the internal 
rectus is seized with the forceps, and incised with the scissors be- 
tween the forceps and the eye. Into the opening thus 
made the points of the closed scissors are inserted, and, 
with a snipping action, a passage is made through the sub- 
. conjunctival tissue — from the conjunctival aperture to the 
upper border of the tendon in case of the left eye, or to its 
lower border in the right eye. The scissors are now laid 
aside, but the conjunctiva is still held in the forceps, and 
with the right hand, the point of the hook is passed 
through the opening and along the passage, until the 
edge of the tendon is reached. The point of the hook 
being kept in contact with the sclerotic, the instrument 
is then turned rapidly round and under the tendon, 
and is brought close up to the insertion of the latter 
into the sclerotic, care being taken that the whole ^^'^' 

breadth of the tendon lies on the hook. The forceps are now 
laid aside, and the hook carrying the tendon is transferred to the 
left hand. One blade of the scissors (held in the right hand) 
41 



i 



490 DISEASES OF THE EYE. 

is now inserted between the globe and the tendon, and the latter 
is completely divided at its insertion. The second hook is then 
employed for searching, above and below, for any strands of the 
tendon which may be left undivided, the test for complete di- 
vision being that the hook can be brought up without obstruc- 
tion to the margin of the cornea. If the smallest segment of the 
tendon be left undivided, the result of the operation is apt to be 
unsatisfactory. Immediately after the operation a marked dim- 
inution in the mobility of the eye inwards should be looked 
for, as this motion can now only take place by aid of any remain- 
ing connective tissue attachments of the muscle to the eyeball and 
capsule of Tenon. If this defect in motion be not present, or in 
only a slight degree in comparison with the supposed extent of 
operation, it may be concluded that the tendon is imperfectly di- 
vided, and a new search with the hook for undivided filaments 
must be made. To estimate this loss of motion it is necessary 
before the operation to note the degree of mobility of the eye- 
ball inwards, and to compare it with the inward motion of the 
other eye. 

The effect of the operation may be diminished, if found neces- 
sary, by drawing the edges of the conjunctival wound to- 
gether with a suture, the tendon being thus prevented from unit- 
ing with the globe so far back. The more conjunctiva we include 
in the suture at each side of the wound the more will the effect of 
the tenotomy be reduced. This restricting suture should be ap- 
plied when the immediate result of the tenotomy is greater than 
expected or desired. 

As the edges of the conjunctival wound cannot be accurately 
adjusted with sutures, none are applied for that purpose. They 
are used, as above, to diminish the operative effect; or, when an 
extensive loosening of the subconjunctival tissue has been per- 
formed, to prevent sinking oi the caruncle. 

The Subconjunctival Operation for Strabismus, proposed by 
the late Mr. Critchett, is performed as follows : A fold of con- 
junctiva is seized close to the lower margin of the insertion of the 
muscle, and incised with a blunt-pointed scissors, so as to expose 
the tendon. A strabismus hook is passed through the opening 
and under the tendon. The scissors is now inserted and opened 
slightly, one point being kept close to the hook, while the other 
is passed between the tendon and the conjunctiva, and the ten- 
don is divided at its insertion. This method is very generally 



THE ORBITAL MUSCLES. 491 

adopted by English surgeons. For myself I prefer the operation 
(von Graefe's) previously described, as it much more readily 
admits of modifications of the effect. 

In von Arlt's Method, instead of a hook being passed under the 
tendon in the first instance, it is seized with the forceps with 
which, just previously, the conjunctiva had been raised. In other 
respects the proceeding is the same as von Graefe's, than which 
it is said to be less painful. 

The immediate and ultimate effects of a tenotomy are by no 
means identical. Immediately after the operation the effect is 
very marked, owing to the loosening of the tendon from its 
insertion. In a few days, when it becomes reattached, the 
effect diminishes, and in the course of some weeks there is again 
an increase in the effect, and this increase continues for about a 
year, as above stated. 

The ultimate result may, with tolerable certainty, be estimated 
immediately after the operation by testing the power of converg- 
ence. If the patient be directed to look with both eyes at the 
surgeon's finger held in the middle line, and it be approached 
to within 12 or 15 cm. of his nose, and if the convergence of the 
eyes can be maintained at that distance, the effect will not be too 
great. But if at a distance of from 18 to 20 cm. the operated eye 
ceases to converge, or begins to diverge, or if even at 12 cm. the 
convergence, although accomplished, cannot be maintained for 
more than a few moments, and if then the operated eye deviates 
outwards, ultimate divergence may be expected, even though the 
actual position of the visual axes be correct. A restricting suture 
must be applied in such cases. 

Sometimes, although the patient converges up to 12 cm. sat- 
isfactorily, and maintains the convergence at that distance for some 
moments, the eye will then rotate inwards. In such cases there 
is apt to be a recurrence of the strabismus. 

Advancement. — In cases of convergent squint, in which it is de- 
sirable to combine advancement of the external rectus with ten- 
otomy of the internal rectus, the latter is done first, as above de- 
scribed, at the same sitting. 

An opening is then made in the conjunctiva immediately over 
the insertion of the external rectus, and as long as the breadth of 
the tendon. The band of conjunctiva between the opening and 
the cornea is separated up with the scissors from the sclerotic, 
for to it the tendon has to be fastened later on. A strabismus 



492 DISEASES OF THE EYE. 

hook is now passed under the tendon, and brought well up to its 
insertion, care being taken that the whole width of the tendon is 
held on the hook. A needle carrying a fine silk suture is intro- 
duced from its upper margin between the tendon and sclerotic, 
and passed through the tendon at its middle line. In the same 
way another suture is passed behind the tendon from its lower 
margin, and through it, close to the first suture. Each of these 
sutures is knotted firmly on the tendon, a long end being left to 
each suture (Fig. 155). The tendon is separated off with the 
scissors from the sclerotic close to its insertion. The sutures are 
passed through the conjunctival flap in the direction of the muscle, 
and are respectively tied with their own ends. A greater or less 
effect is produced according as the sutures are placed farther or 
nearer to the insertion of the tendon, and according as they are 




Fig. 155. 

drawn more or less tightly. I have found this method perfectly 
satisfactory. 

Immediately after the combined operation is finished there 
should be no divergence, nor should there be marked loss of motion 
of the eyeball inwards. In either case the effect is too great, and 
must at once be diminished by an adjustment of the advancing 
sutures, or a bringing forward of the internal rectus. 

In my opinion, even if it lie in the plan of the treatment to sup- 
plement the tenotomy (or combined operation) on the squinting 
eye by a tenotomy (or combined operation) on the fixing eye, 



THE ORBITAL MUSCLES. 493 

both eyes should not be operated on at one and the same sitting. 
An interval of a fortnight or more should elapse, in order that the 
true effect of the first proceeding may be accurately gauged, and 
then the surgeon will be in a position to know how to regulate his 
operative measures for the other eye. 

After a strabismus operation, a light dressing is applied, and is 
changed morning and evening for forty-eight hours, when, if no 
suture has been used, it may be discarded. If sutures have been 
employed, the dressing is retained until they come away. 

Dangers of the Strabismus Operation. — I have never seen any 
inflammatory reaction after strabismus operation, not even 
after an advancement, nor have I ever seen any serious acci- 
dent during the operation. Puncture of the sclerotic with the 
scissors while the tendon was being divided has occurred in the 
hands of some operators ; but I confess I cannot understand how 
such an accident could happen, unless the operator had his own 
eyes shut. It is also stated that eyes have been lost after squint 
operations through orbital cellulitis, which, beyond doubt, must 
have been brought on by the introduction of septic matter upon 
the instruments. 

Occasionally a small arterial branch may be divided during the 
operation, and this, bleeding into the capsule of Tenon, may cause 
rather alarming exophthalmos. The protrusion goes back in a 
few days with use of a pressure bandage. I have only seen the 
occurrence twice. 

Sinking back of the caruncle, some months after the tenotomy, 
when it does rarely occur, can be remedied in the following way : 
The conjunctiva is divided vertically about 6 mm. from the 
caruncle. The inner lip of the wound is raised, a scissors curved 
on the flat passed in, and the subconjunctival tissue as far as under 
the sunken caruncle separated. The subconjunctival tissue under 
the outer lip of the wound, and as far as the corneal margin, is 
loosened in the same way, and the two flaps are brought together 
with a suture, which includes a sufficiency of conjunctiva to draw 
the caruncle well forwards. 

Treatment subsequent to Operation. — It is generally necessary 
for the patient to wear the correcting spectacles for his hyper- 
metropia either constantly or for near vision only, according as 
the result of the operative measures makes it more or less de- 
sirable to suspend the accommodation. After some months it is 
usually possible to leave off the spectacles, except for near vision, 



494 DISEASES OF THE EYE. 

A cure of the strabismus, in the sense of removal of the de- 
formity, can be attained by operation, and by itself affords ample 
indication for the operation. But a cure, in the true sense of the 
term, involves restoration of binocular vision,* and this is very 
rarely obtained by operative measures alone. To this end the 
operation must be followed up by orthoptic treatment. 

Insufficiency of Convergence, or Insufficiency of the In- 
ternal Recti Muscles, and Divergent Concomitant Strabis- 
mus. — In the normal condition the orbital muscles are in a state 
of equilibrium, no one muscle or pair of muscles having more 
power over the eyeballs than its fellow. 

Insufficiency of the Internal Recti Muscles, or Insufficiency of 
Convergence, as it is more correctly called, implies a disturbance 
of this equilibrium. The converging power of the internal recti, 
in these cases, is so much weakened that they are obliged to make 
a constant effort to prevent the eyes, or one of them, from becom- 
ing divergent, and it is only the demand for binocular vision which 
stimulates the muscles to this effect. 

Muscular Asthenopia is the symptom caused by this insuffi- 
ciency. The patients complain that, after reading, writing, sew- 
ing, or employment at other near work for a time, they begin to 
find the objects spreading, becoming indistinct, and perhaps 
doubled. Pain in and about the eyes comes on. These symp- 
toms gradually increase, until the work has to be discontinued. 

A great deal has been written within recent years upon the re- 
lationship of some nervous diseases, especially epilepsy, to want of 
power in one or more of the orbital muscles. It has been thought 
that " eye strain," from want of co-ordination in these muscles, 
sometimes aggravated, if it did not actually cause, epilepsy; but 
the outcome of the whole discussion seems to be that there is no 
such connection. 

The diagnosis of insufficiency of convergence can be made by 
the following methods : 

(a) The patient is directed to look at the tip of the surgeon's 
finger held up in the middle line. The finger is brought slowly 
closer to the eyes until a certain point is reached where the inter- 
nal rectus of one eye ceases to act, the other eye still remaining in 

* The importance of binocular vision consists in the fact that it is 
chiefly by its aid we estimate distances finely and observe the shape of 
objects. Even plane surfaces are seen much more accurately with binocu- 
lar than with monocular vision. 



THE ORBITAL MUSCLES. 



495 



fixation. The first eye, upon the finger being advanced a Httle 
more, usually becomes divergent. 

(b) If the tip of the finger be held some 20 cm. from the pa- 
tient's eyes, and if, v^ith his other hand, the surgeon cover one of 
the eyes, say the right, v^hile the left is caused to fix the finger- 
tip, it will be found that the eye under the hand is diverging, and, 
when the hand is removed from it, it makes an inward motion, in 
order again to fix the finger-tip. The explanation of this 
is that when one eye is covered there is nothing to be 
gained in the way of single vision by an excessive exer- 
tion of the weak internal recti ; and consequently the eye 
which is excluded from the act of vision is abandoned to 
the control of the external rectus, and only returns to its 
normal position when, being restored to participation in 
the act of vision, diplopia would otherwise be present. 

(c) The following is Von Graefe's Test for insufiiciency 
of the Internal Recti : A dot with a. fine line drawn ver- 
tically through it (Fig. 156) on a sheet of white paper is 
given to the patient to look at, at his usual reading dis- -pic. is6. 
tance. Before one eye, say the right, a prism of about 

10° with its base downwards is held vertically. This, 
in the normal condition, would produce a double 
image of the dot, so that the figure would seem to be 
a line with two dots, the upper dot being the image 
belonging to the right eye. In insufiiciency of the 
interni, the image of the right eye would not only be 
higher than that of the left, but it would also stand 
to the left (crossed double images) more or less, so 
that here the picture is that of two lines, each with a 
dot, the upper line and dot standing to the left-hand 
side (Fig. 157). This crossed diplopia indicates 
divergence. The explanation of the experiment is 
as follows : When a prism is held before the right 
eye, the possibility of binocular vision is removed, 
and, insufiiciency existing, the weak internal rectus 
of the right eye has no object in greatly exerting 
itself, and, consequently, abandons the eye to the 
Fig. 157. traction of the external rectus. Hence the divergence 
and the projection of the image of this eye to the 
opposite side. The degree of insufficiency existing may be deter- 
mined by this same experiment. If a weak prism be held with its 



496 



DISEASES OF THE EYE. 



base inwards before the left eye, in the above case, the images of 
the hnes will appear to be brought closer. By gradually proceed- 
ing to higher prisms, one will be found which brings the lines 
together, so that the picture will now be that of two dots over 
each other on one line. This prism is the measure of the 
insufficiency. 

(d) Landolt estimates the amount of insufficiency of conver- 
gence by means of the meter angle and amplitude of convergence. 
For an account of the method I must refer the reader to his valu- 
able work.^® 

(e) Maddox's Rod Test is an admirable method for ascertain- 
ing the condition of the muscular equilibrium of the eyeballs, and 
for estimating any existing derangement of it. 

The apparent lengthening of a flame into a line of light, when 
looked at through a strong cylinder, is utilized to make the two 
images so dissimilar that no desire to unite them remains. The 
chief advantage of this principle is that slight malpositions do not, 




Fig. 158. 

as with prisms, vitiate the result materially. A glass rod mounted 
in a circular metal disc, as in Fig. 158, may be used; or a piano- 
cylinder with a radius of about 20 mm. ; or a piece of corrugated 
glass; or a flat series of thin glass rods side by side. The best 
flame to employ is that of a gas-jet turned low, at a distance of 
5 mm. or 6 mm., and the appearance is improved by a piece of blue 
glass before the other eye, to equalize the illumination of the two 
images. The line of light is at right angles to the axis of the 
cylinder. If it pass through the flame, the balance is perfect ; if 
not, the defect is measured by the deviating angle of the prism 
which is found to bring them together, or, preferably, by a litho- 



THE ORBITAL IMUSCLES. 497 

graphed scale, placed with its zero just behind the flame, so that 
the figure crossed by the line of light gives the deviation in de- 
grees. For vertical diplopia the scale should be vertical, and for 
horizontal diplopia horizontal. In either case the axis of the 
cylinder should be parallel to the scale. When the cylinder is 
vertical it should be shaded from the light of the window. By 
placing the patient's head in different positions the diplopia can 
be measured in all parts of the motor field. Vertical and hori- 
zontal scale should, for this purpose, be fixed on the wall, with 
their zeros coinciding at the position of the flame. For near- 
vision tests a flame is too large. A scale should be used on a 
black background, with a small silvered hemisphere or bead fixed 
to its zero, to be a source of reflected light from the window or 
from a flame. 

This test is also very serviceable in overcoming the suppres- 
sion of the false image in old squints, and for discovering the 
latent paresis of an ocular muscle. 

Insufficiency of the internal recti is a common attendant upon 
myopia, but it is also found with emmetropia, and even with 
hypermetropia. 

Concomitant divergent strabismus is a further development of 
the same condition. 

Treatment. — In moderate degrees of myopia the use of such 
concave glasses as will permit the patient to read at 35 cm. dis- 
tance may relieve the asthenopic symptoms. 

Decentration of these glasses may give further aid. If the 
glasses be so set in the spectacle-frame that their centers are on 
the outer side of the visual lines, the inner half of the glasses act 
as prisms with their bases inwards, and by them the rays are 
broken inwards — i. e., towards the macula lutea in each eye, so 
that a slight divergence may take place without diplopia, etc. In 
this way the internal recti are relieved. Should the case be one 
demanding the use of convex .glasses (hypermetropia, presbyopia) 
the decentration must be inwards. 

A more perfect and accurate method is that of prescribing 
prisms, bases inwards, to be worn for reading and other near 
work. These may be combined with concave or convex glasses, 
where such are indicated. The prism which is the measure of the 
insufficiency (see above) is divided between the two eyes. If it 
be 4°, a prism of 2° is placed, base inwards, before each eye for 
near work. Very high prisms cannot be ordered, owing to the 

42 



498 ^ DISEASES OF THE EYE. 

color effects they produce; and in cases where they would be re- 
quired the insufficiency can be only partially corrected by prisms. 

Operative Treatment. — This consists in weakening the too 
strong external rectus by tenotomy. The danger of the method 
is that convergent strabismus with homonymous diplopia for dis- 
tant objects may result, unless the case be suitable for operation. 
Only those cases are suitable in which absolute divergent strabis- 
mus is present; or those in which, with a prism of not less than 
10°, base inwards, before one eye, the flame of a candle at 3 m. 
distance is seen single, or if it be perhaps doubled for a moment, 
then becoming again single. When with such a prism single 
vision is present, the external rectus by an effort must have over- 
come the effect of the prism, and it is admissible to deprive the 
muscle of the power represented by that effort or prism. If 
diplopia be produced by a prism of 10°, the tenotomy is contra- 
indicated, for the effect of the latter could not be modified to the 
slight power of abduction indicated by a weaker prism. A source 
of error in the ascertaining of this abduction prism, which must 
be guarded against, is that the patient may suppress the image of 
one eye, and that his single vision may be merely due to the fact 
that he is seeing with the other alone. The higher the abduction 
prism, the more extensive may be the division of the subcon- 
junctival tissue, etc., while with weak abduction, the effect must 
be diminished by a conjunctival suture. 

Immediately after the operation there should be a certain 
amount of convergence, as shown by homonymous diplopia in the 
middle line for the flame of a candle at 3 m. distance. This con- 
vergence, or diplopia should not be greater than can be corrected 
by a prism of 10°. Moreover, if the candle be moved from the 
middle line 15° to the opposite side from the operated muscle (to 
the right if the left external rectus has been tenotomized), there 
should be no convergence (no diplopia), and a vertical prism be- 
fore one eye should only cause double images placed directly over 
each other. If, by these experiments, it be shown that the opera- 
tion has produced an excessive effect, the latter must be dimin- 
ished by a suture drawing the lips of the conjunctival wound 
together, and including more or less conjunctiva, according to the 
excess to be corrected. Or, if a suture have already been applied, 
and the result be still in excess, it must be withdrawn, and a still 
more restricting suture inserted. In all these cases, convergence 
must necessarily be present, when the candle is carried over to the 



THE ORBITAL MUSCLES. 499 

side of the operated muscle; but this disappears — except perhaps 
at the very most extreme position on that side — as also the con- 
vergence in the middle line, by reason of cicatricial contraction at 
the new insertion of the tendon ; always provided that the indica- 
tions for the operation and its performance, as above set forth, 
have been accurately attended to. 

Nystagmus. 

This term indicates an involuntary oscillation of the eyeballs 
laterally (the most common form), vertically, or with a rotary 
motion (caused by the oblique muscles). 

It is most commonly found with congenitally defective vision — 
microphthalmos, coloboma of the chorioid, in albinos, etc. ; but it 
may be acquired, and is often seen, in those employed in coal- 
mines. It occurs in about one-half the cases of disseminated 
sclerosis.* 

In the congenital cases it is probable that the absence of the 
stimulus which accurate retinal impressions afford interferes 
with the functional development of the co-ordinating centers for 
the orbital muscles. In coal-mines, the very defective light, and 
the blackness of the surroundings, deprive the miners of any de- 
fined retinal impression, and hence their co-ordinating centers are 
apt to become deranged. But as it is chiefly those who work in 
one constrained position on their sides, with eyes directed obliquely 
upwards, who become affected, it seems probable ^^ that this un- 
natural, and long-continued direction of the eyeballs is an impor- 
tant factor in the production of the affection ; indeed, it may be to 
a great extent a professional cramp, like writer's cramp. In fact, 
a case of acquired nystagmus in a compositor, due to working in 
a strained position, has been recorded by Snell.^^ 

Those patients, in whom nystagmus is due to a congenital de- 
fect of vision, dp not complain of oscillation of the objects they 
look at ; but individuals, who become affected with it in later life, 
are much troubled with that symptom, especially at the onset. 

Treatment. — In congenital cases, which admit of improvement 
of vision, a cure, partial or complete, is sometimes brought about 

* According to Gowers ("Diseases of the Nervous System," vol. i. 2d 
Ed.), nystagmus ocpurs often in ataxic paraplegia, primary spastic para- 
plegia, and hereditary ataxia, sometimes in severe multiple neuritis and 
syringomyelia, but rarely in progressive muscular atrophy. 



500 DISEASES OF THE EYE. 

when the vision improves. If strabismus be present it should be 
cured, after which a diminution in the oscillations may result. In 
miner's nystagmus, the all-important measure is a permanent re- 
linquishment of mine work; and this is frequently followed by 
satisfactory results. 

References. 

^ Landolt and Wecker, " Traite d'Ophtal.," vol. iii. p. 782. 

^ " Ophthalmic Review," v. p. 65. 

'c " Trans. Ophth. Soc, U. K.," ix. p. 191. 

'b " Brit. Med. Jour.," March 3, 1900. 

^ " Brain," Summer, 1900. 

* First proposed by Professor J. Michel, " Klin. Monatsbl. f. Augen- 
heilk.," 1887, p. S73. 

^ " Ueber das Schielen " and " Handbuch der Augenheilkunde," 5th 
ed., p. 146. 

** " Bowman Lecture," 1889, 

^ " Bowman Lecture," 1898. 

' " Centralblatt. f. p. Augenheilkunde," 1886, p. 5. 

'"Annales d'Oculistique," Juillet et Aout, 1871. See also Mars et 
Avril, Mai et Juin, and Nov, et Dec, for the same year. 
^° " The Refraction and Accommodation of the Eye," p. 501. 

^^Vide S. Snell, "Brit. Med. Journ.," July 11, 1891. 
*"" Trans. Ophthal. Soc, U. K," xi. p. 102. 



CHAPTER XVIII. 
DISEASES OF THE ORBIT. 

Orbital Cellulitis. — The Symptoms of this affection are: 
erysipelatous swelling of the lids, especially of the upper Hd; 
serous chemosis ; pain in the orbit, increased on pressure of the 
eyeball backwards ; violent facial neuralgia ; exophthalmos, with 
impairment of the motions of the eye in every direction ; and high 
fever. 

Vision is not generally affected, but sometimes it is so from 
optic neuritis, and then, too, mydriasis is seen. The cornea is 
often completely or partially anesthetic. 

The surgeon, by pressing the tip of his fourth finger between 
the eyeball and the margin of the orbit, may feel a more or less 
resistant tumor. This gradually increases in some one direction, 
the integument in that position becomes redder, fluctuation be- 
comes pronounced, and the abscess finally opens through the skin, 
or into the conjunctival sac, the pointing being usually at the 
upper and inner angle of the orbit. Restoration to the normal 
state, as a rule, comes about; but in some cases complete atrophy 
of the optic nerve supervenes. 

Causes. — (i) Idiopathic (e. g., cold) ; (2) traumatic (perforat- 
ing injuries, foreign bodies) ; (3) extension of inflammation from 
surrounding parts (erysipelas, diseased tooth, ethmoidal cells) ; 
(4) metastasis, (pyemia, metria) ; (5) sequelae of fevers (scarla- 
tina, typhoid, purulent meningitis, influenza). 

Treatment. — Locally, poultices or warm fomentations; and 
when pus has formed, its earliest possible evacuation — ^by prefer- 
ence from the conjunctival sac. The general constitutional 
treatment suitable to each case need not be discussed here. 

Thrombosis of the Cavernous Sinus gives rise to symptoms 
which may be mistaken for those of an orbital process. The 
affection is described at p. 469. 

Periostitis of the Orbit. — Acute periostitis has many symp- 
toms in common with phlegmonous inflammation of the orbital 
connective tissue which generally accompanies it ; but may usually 

501 



502 DISEASES OF THE EYE, 

be distinguished from the latter inflammation occurring independ- 
ently by the fact, as first pointed out by the late Mr. John Hamil- 
ton, of Dublin,^ that in it pressure on the orbital margin is pain- 
ful. The absence of this tenderness, however, is not always con- 
clusive of the absence of periostitis, especially when the latter is 
restricted to the deep parts of the orbit. In periostitis, the eyelids 
are not usually so swollen as in inflammation of the orbital tis- 
sues. Suppuration may take place, necrosis in consequence of 
detachment of the periosteum may come on, and communications 
with the neighboring cavities may be formed. 

In secondary syphilis, or in later stages of the disease, a 
syphilitic gumma of the orbital wall may form. This is accom- 
panied by violent frontal neuralgia or headache, increasing at 
night. Proptosis (Ttpo^ forwards; 7tr(S>ai?, falling), or protrusion 
of the eyeball occurs, with marked loss of motion in the eyeball in 
one or more directions. This loss of motion is a very character- 
istic symptom, and serves to assist in the diagnosis between this 
affection and other orbital tumors. It is probably due to an ex- 
tension of the inflammation to the connective tissue of the orbit, 
and to the muscles themselves. 

Very suggestive of gummatous periostitis of the orbit are: A 
rapidly increasing proptosis, with displacement of the globe down- 
wards and forwards, and much loss of motion of the eye, and on 
palpation the sensation is given to the finger of a tumor in the 
roof of the orbit, where gummata most commonly are situated. 
Also, thickening of the upper margin of the orbit, with pain on 
pressure o{ the roof of the orbit, and radiating peri-orbital pain at 
night. 

Again, periostitis of a chronic form, and without tendency 
to suppuration, occurs most commonly in persons with a constitu- 
tional rheumatic tendency. It is accompanied by pain in and 
about the orbit, and there is increased tenderness on pressure of 
the eyeball backwards. Exophthalmos, and all other outward 
signs, are here usually wanting. 

The Prognosis depends much on the seat of the inflammation. 
If this be in the deep parts of the orbit, thickening of the perios- 
teum may cause permanent protrusion of the eyeball ; extension of 
the inflammation to the optic nerve may result in optic atrophy ; 
the orbital muscles, or the nerves which supply them, may be im- 
plicated, with consequent paralysis ; or, finally, the inflammation 
of the periosteum may strike into the meninges of the brain. 



THE ORBIT. 503 

When the inflammation is near the margin of the orbit, early 
evacuation of pus, if it has formed, reduces the process within 
safe bounds ; and this position is one of less danger in respect of 
its surroundings, than if the process be deep in the orbit. 

Causes. — Periostitis of the orbit may be caused by blows or other 
traumata, by extension from neighboring cavities, by syphilis, or 
rheumatism. 

Treatment. — Warm fomentations. Exit given to pus, if pos- 
sible. Constitutional measures. 

Caries of the Orbit is very frequently the result of periostitis, 
but often commences in the bone, and in either case is usually due 
to tubercular disease. It is also seen in very late syphilis. A 
trauma is sometimes the immediate cause of its onset. 

It may attack any part of the orbital walls, its favorite seats 
being the margin above and to the outside, or below and to the 
outside. When it is seated deeply in the orbit, it often causes 
exophthalmos and pain. At the margin of the orbit it produces 
edema and swelling of the eyelids, with conjunctivitis; suppura- 
tion comes on, and the abscess finally opens through the integu- 
ment or conjunctiva. A fistula is apt to remain for a length of 
time, and, the skin being drawn into this, ectropion of the lid is 
produced. If a portion of dead bone comes away, the resulting 
cicatrix is liable to maintain the ectropion (p. 228). 

Treatment. — The evacuation of purulent collections at the 
earliest possible moment — if deep in the orbit, by the careful intro- 
duction of a long bistoury — the insertion of a drainage-tube, and 
the regular washing out of the cavity with antiseptic solu- 
tions, until no more rough or bare bone can be felt with the 
probe. 

Injuries of the Orbit. — Wounds of the soft parts in the supra- 
orbital region, involving the supra-orbital nerve, are held by some 
to be capable of producing a reflex amaurosis (p. 554), and many 
such cases have been recorded under the name of supra-orbital 
amaurosis. By the light of modern physiology and ophthalmology 
it is not probable that any such reflex could take place. It seems 
more likely that the blindness in the cases recorded was brought 
about in some other way — e. g., injury to the optic nerve in the 
optic foramen by the concussion, or by a fracture of the margin 
of the foramen, orbital periostitis, concomitant injury to the 
eyeball itself, facial erysipelas, intracranial lesions, and so on. 

It may be, however, that a functional amblyopia, or amauro- 



504 DISEASES OF THE EYE. 

sis, similar to that occasionally seen, after long-continued 
blepharospasm (p. 136), has been present. 

Perforating injuries of the orbit through the eyelids by prods 
of walking-canes, etc., and the lodgment of foreign bodies in 
the orbit are serious accidents. They are liable to be followed 
by phlegmonous inflammation; or, if a pointed weapon (stick, 
sword-cane, etc.) has been pushed into the orbit with some force, 
it may pass through the bony wall and perforate the brain, with 
fatal result. 

It is remarkable what large foreign bodies may be concealed 
in the orbit. I once saw a case in which a bit of wood, 3-4 inch 
long by 1-2 inch wide, lay unsuspected in the orbit for many 
weeks, without causing any marked displacement of the eyeball. 

Treatment. — Foreign bodies should be removed by dilatation 
of their wounds of entrance, or by the formation of a new pass- 
age through the conjunctival fornix — and great care should be 
taken to prevent the onset of inflammation, or to keep it within 
safe bounds. 

Enophthalmos, or sinking of the eye back into the orbit, 
occurs to a certain extent in extreme emaciation, in Asiatic 
cholera, in paralysis of the sympathetic and in facial hemiat- 
rophy, but it has been observed tO' an extreme degree as a result 
of injury. Beer ^ attributes it to atrophy of the retrobulbar 
cellular tissue ; Lang ^ explains it by fracture or depression of 
a portion of the orbital wall; while Schapringer* refers the con- 
dition to paralysis of Miiller's muscle from injury of the sym- 
pathetic nerve. 

Orbital Tumors. — In the Diagnosis of an Orbital Tumor 
three questions present themselves : — First, Is a tumor of the 
orbit present? Secondly, Is the new growth confined to the 
orbit, or does it extend to neighboring cavities? and thirdly, Of 
what kind is the new growth? The diagnosis as regards any 
of these points does not often occasion much difficulty in ad- 
vanced stages of the disease, especially where the growth occu- 
pies the anterior part of the orbit, or protrudes from it. It is 
rather in the early and middle stages that difficulties in diagnosis 
are apt to present themselves, and attention will here be mainly 
directed to those stages. 

Exophthalmos is, of the signs by which the presence of a 
tumor is diagnosed in its early stages, by far the most impor- 
tant, because it is the most constant. In the earliest stages of 



THE ORBIT 505 

a growth which commences in the deepest part of the orbit there 
may be, it is true, no exophthahiios, while other symptoms — de- 
fects of sight, pain, loss of motion — may already be present; 
bnt when the growth' attains to certain dimensions, or if in the 
anterior part of the orbit there be even a small tumor, the eye- 
ball must be pushed out of its place. 

An important diagnostic point in connection with the exoph- 
thalmos caused by a tumor — other than one within the muscular 
cone — is that its direction is almost always oblique and not 
straight forwards, for orbital tumors commonly tend to develop 
more along some one wall of the orbit than along the others, and 
hence the eyeball becomes pushed towards the opposite side as 
well as forwards. In cellulitis, edema of the orbital tissues, 
Graves' disease, and paralytic proptosis the exophthalmos has 
a direction straight forwards. Tumors growing from the apex 
of the orbit may, in their early stages, cause no obliquity of direc- 
tion in the displacement of the globe, and some tumors do not 
do so even in an advanced stage of their growth ; but these cases 
are exceptional. Tumors, too, situated altogether within the 
muscular cone, of which the most common are tumors of the 
optic nerve, need not cause any lateral displacement of the globe. 
Again, the exophthalmos caused by an orbital tumor usually 
increases in degree slowly and gradually, differing in this re- 
spect from exophthalmos due to most of the other causes, in 
which either a sudden or a rapid development of the exorbitism 
is the rule. While tumors are sometimes present in both orbits, 
especially lymphoma or lympho-sarcoma, yet it is infinitely more 
common for one orbit alone to be diseased ; and hence mono- 
lateral exophthalmos is suggestive of orbital tumor. 

Palpation in the Orbit often provides a valuable sign, should 
the new growth have come within reach in the anterior part of 
the cavity. In many cases, indeed, there is no difficulty what-= 
ever in recognizing the presence of an orbital tumor by this 
means, the sensation obtainable by the tip of the surgeon's fin- 
ger pressed into the orbit being very definite; but in other cases 
the evidence is not so clear, and a reasonable doubt may exist as 
to whether any abnormal resistance is met with. By palpation 
we may gain some knowledge of the position, extent, shape, and 
consistence of the tumor, and whether it be adherent either to 
the walls of the orbit or to the eyeball. It is important, when 
practicable, to compare the result of examination of the dis- 



5o6 DISEASES OF THE EYE. 

eased orbit with the condition of the sound orbit; and this can 
be done to greater advantage, if palpation of the orbits be per- 
formed simultaneously with a finger of each hand. 

The Rontgen Rays have been successfully employed in some 
cases for the diagnosis of retrobulbar growths. 

Derangements of Vision are often, but by no means always, 
present in the early and middle stages of the growth of an 
orbital tumor. Their occurrence depends frequently on the 
rapidity of the growth of the tumor rather than upon its size. 
In an early stage of a rapidly increasing tumor the sudden 
stretching of, and pressure on the optic nerve may produce ab- 
solute blindness ; while in another case, with an equal degree of 
exorbitism, but which has been brought on by a slowly growing 
tumor, vision may be unaffected by reason of the optic nerve 
becoming gradually accustomed to the change. Yet slowly 
growing tumors, which spring from the optic nerve or its neigh- 
borhood or from the deepest part of the orbit, are competent, by 
direct pressure on, or by implication of the optic nerve, to cause 
serious loss of sight, even in an early stage, and with but little 
exophthalmos. Optic neuritis, and, later on, optic atrophy, are 
occasionally discovered with the ophthalmoscope. Diplopia is 
often present when the globe is at first displaced, but disappears 
when the exophthalmos becomes extreme or the vision defective. 

Pain is a symptom sometimes, but by no means always present 
in cases of orbital tumors. It is especially liable to be com- 
plained of when the growth is increasing rapidly in size, even 
though it may not have attained to great dimensions. The pain 
is then often of a neuralgic kind, and very severe, from the un- 
accustomed pressure on branches of the fifth nerve in the orbit. 

Loss of Power of Motion of the Eyeball is a very common 
symptom in cases of orbital tumors. It is caused in some cases 
by the mechanical obstruction offered by the tumor, as a result 
of which motion of the eyeball becomes defective towards the 
side of the orbit on which the new growth is situated. In other 
cases the loss of motion is caused by stretching of the muscles 
from the exophthalmos, or by implication of them in the new 
growth, or by atrophy of their tissue, or by paralysis of the 
orbital nerves from pressure. When there is little or no loss of 
motion, while the exorbitism is marked, the conclusion may be 
drawn that the tumor lies within the muscular cone. 

In every case the history, the rapidity of growth, the age and 



THE ORBIT. 507 

general condition of the patient are important items for con- 
sideration. 

Diagnosis of the Nature of an Orbital Tumor. — As regards 
the nature of the growth which may be present, it must be ad- 
mitted that in many instances, in the early stages of a deeply 
seated tumor, we have to rest content with an indefinite or pro- 
visional diagnosis, unless an exploratory operation, with 
puncture or harpooning of the mass, is practicable; and such a 
procedure is often called for, in order to decide not only the 
nature of the tumor, but also its extent and origin. 

Orbital Cysts. — Dermoid cysts are those most frequently 
found, and they are usually congenital. Indeed, if an orbital 
tumor be congenital, it is, as a rule, either a dermoid cyst or an 
encephalocele. Dermoid cysts, although usually congenital, do 
not often grow to any size until the age of puberty or later, and 
may then for the first time give rise to troublesome symptoms. 
They grow slowly, and finally reach very considerable size, and 
then bulge out between the eyeball and margin of the orbit. 
Pressure upon this protruding part causes it to diminish, while 
the exophthahnos is at the same time increased, and distinct 
fluctuation in the protruding part can be felt. The growth of 
the cyst is unaccompanied by pain or other inconvenience. The 
contents are generally either serous or honey-like, and occa- 
sionally hairs and other epidermic formations have been found 
in them. 

Hydatid cysts also occur in the orbit, and several of these 
cases have been observed in England. 

Treatment. — The cysts should be freely opened at the most 
prominent point, evacuated by gentle pressure backwards of the 
eyeball, and the sac syringed out two or three times daily with 
an antiseptic solution, until all discharge has ceased. The open- 
ing will then close, while the eyeball will already have returned 
to its place. If the contents of the cyst are solid, or nearly so, 
it becomes necessary to extirpate it in tofo. To do this, Kron- 
lein's operation (p. 515) must be resorted to. Or, a horizontal 
incision may be made along the orbital margin through the eye- 
lid, in order that the cavity of the orbit may be reached, or two 
perpendicular incisions at either canthus through the upper lid 
may be made, and the latter turned upwards. With hooks or 
forceps, and scalpel or scissors, the cyst wall must then be care- 
fully separated from all adhesions. 



5o8 DISEASES OF THE EYE. 

Exostoses occur as the result of inflammation of the bone and 
of periostitis, and also without any apparent cause, and are 
usually of the kind known as ivory exostoses. They spring 
most commonly from the ethmoid or from the frontal bone. 

All the bony tumors give, of course, the sensation of dense 
hardness to the touch ; but there are some malignant growths of 
such hardness that it may not be easy to tell them from the osteo- 
mata by palpation, and an exploratory puncture becomes neces- 
sary in order to decide the point. The growth of an orbital 
osteoma is excessively slow, in many instances commencing in 
infancy, and lasting into advanced life. In addition to the dense 
hardness of these tumors, the deciding points in the diagnosis 
are their usually globular and somewhat nodulated surface, and 
their immobility and direct connection with the walls of the 
orbit ascertainable by touch. 

Operative interference in cases of exostosis of the orbit is 
only justifiable when the tumor docs not grow from the roof 
of the orbit (as it then often involves the cranial cavity), and 
when there is reason to think it is attached to the orbital wall 
by a narrow base or pedicle. Several instances are on record 
in which the growth has become spontaneously separated by 
necrosis of its pedicle. Beyond destruction of the eyeball there 
is no danger associated with these tumors, even if their growth 
takes an intracranial direction; but they cause serious disfigure- 
ment and much pain. 

Carcinoma and Sarcoma. — The first of these tumors takes its 
origin in some neighboring cavity, or from within the eyeball, 
and grows into the orbit ; it never originates in the orbit. Sar- 
coma may originate in many different positions, most frequently, 
perhaps, in the periosteum and in the connective tissue about the 
lacrimal gland. These malignant tumors, after destruction of 
the eyeball by pressure, or by phthisis following ulceration of 
the cornea, attack the bony walls (of the orbit and its sur- 
roundings. 

The early extirpation of the tumor with complete eviscera- 
tion of the orbital contents affords, in general, the only prospect, 
and that a slight one, of saving the patient's life. 

Many forms of sarcoma, however, are non-malignant, espe- 
cially those which lie free in the orbit and arise from the con- 
nective tissue. Indeed, Panas '' held that many cases of sar- 
coma, as also of lymphadenoma of the orbit, are due to infectious 



THE ORBIT. 509 

principles, toxins, or microbes, and are amenable to medical 
treatment by mercury, iodin, arsenic, or toxitherapy. So much 
certainly must be admitted — namely, that cases now and then 
present themselves, with all the signs and symptoms of orbital 
tumor, which ultimately undergo a purely spontaneous cure, or 
one unexpectedly brought about by iodid of potassium. 

Symmetrical Tumors of the Orbits. — With the exception of 
tumors of the lacrimal glands, and possibly of rare instances of 
metastatic tumors, symmetrical tumors of the orbits are almost 
invariably lymphomata or lymphadenomata, occurring in leu- 
kemia or in pseudo-leukemia. 

Pulsating Exophthalmos. — This title covers a great variety 
of vascular tumors, the majority of them having their origin 
within the cranium, while the remainder are truly orbital. 
Symptoms common to all these are : proptosis ; the presence of 
peculiar bruits, which can be heard over the orbit, and usually, 
also, over a more or less extensive portion of the skull ; and pul- 
sation, apparent in the eyeball, or at some point of the orbital 
aperture. The last symptom may occasionally be absent during 
the whole, or part, of the progress of the case. The intra- 
cranial vascular tumors with which we are most likely to meet 
are : aneurysm of the ophthalmic artery at its point of origin 
from the internal carotid; aneurysm of the latter vessel; and, 
most commonly, arterio-venous aneurysm from communication 
of the internal carotid with the cavernous sinus — this latter of 
traumatic origin. In the orbit the following occur: True 
aneurysm of any of the arterial branches; diffused or circum- 
scribed traumatic aneurysm ; arterio-venous aneurysm, of trau- 
matic origin ; aneurysm per anastomosis ; and telangiectic tumors. 

Hemorrhage is liable to prove fatal in these cases. 

Treatment. — Ligature of the common carotid affords the best 
prospect of cure. Digital compression of the same vessel has 
produced cure in some cases. Spontaneous cure has been ob- 
served occasionally in cases of arterio-venous aneurysm. 

Implication of Neighboring Cavities. — As regards the ques- 
tion whether the tumor is confined to the orbit, or involves one 
or more of the neighboring cavities, it may be assumed that it is 
confined to the orbit, unless there are symptoms or signs which 
point in the opposite direction ; and in each case these symptoms 
and signs ought to be looked for. Tumors may either origi- 
nate in one of these spaces and grow into the orbit, which is the 



5IO DISEASES OF THE EYE. 

more common event; or, originating in the orbit, they may at a 
later stage spread to a neighboring space ; and it is often the his- 
tory or progress of the case alone that can inform us which of 
these events has taken place. 

Tumors w^hich originate in the Frontal Sinus are usually 
either mucocele or exostosis. Mucocele of the frontal sinus 
frequently extends to the ethmoidal sinus and thence first en- 
croaches on the orbit, pushing the eyeball dov^nwards and out- 
v^ards. Sometimes there is supra-orbital pain, and sometimes, 
when the nasal meatus has become involved, there is discharge 
from the nostril. The diagnosis in these cases is often obscure. 
Osteoma of the frontal sinus shows itself as a slowly growing 
and densely hard tumor almost free from pain, situated along 
the superior margin of the orbit, extending into the latter and 
pushing the eyeball downwards and forwards. It may subse- 
quently extend to the orbital plate of the ethmoid. An error in 
diagnosis is, I think, liable to be made sometimes when a tumor 
of the frontal sinus drives the outer table downwards and for- 
wards, and when the latter gives to the touch the sensation of a 
bony growth. If the tumor also involves the ethmoid cells, the 
lacrimal bone is apt to be similarly driven forwards, and the 
liability to the error I have mentioned is further increased. 
Bony growths originating in the orbit may invade the frontal 
sinus, and, whether originating there or in the sinus, are liable 
to produce absorption of the tables of the skull without any 
cerebral symptoms to indicate the occurrence. 

Tumors of the Ethmoid Cells, which encroach upon the orbit, 
are likewise most commonly either mucocele or osteoma. 
Mucocele of the ethmoid cells presents itself in the orbit as a 
tumor, gradually increasing in size, on the inner wall of the 
orbit, and pushing the eyeball outwards and forwards. When 
it has grown sufficiently large, palpation of it will discover 
fluctuation. The source of error just referred to, when the lac- 
rimal bone is pushed in front of a slowly growing tumor of the 
ethmoid cells, must be borne in mind. The sharp posterior edge 
of the lacrimal bone is easily felt for and found, and will direct 
the diagnosis into the proper channel. Mucocele of the ethmoid 
cells encroaching on the orbit must also be distinguished from a 
dermoid cyst, but to this I shall return later on. Osteoma of 
the ethmoid appears in the orbit as a hard round swelling at the 
inner canthus, followed by a swelling of the cheek and displace- 



THE ORBIT. 511 

ment of the eye outwards and forwards. It is apt also to extend 
into the nasal meatus, driving the septum out of place, and push- 
ing the hard palate downwards, so that examinations of the nose 
and of the mouth should be made in aid of the diagnosis. 
Enchondromata and fibromata also sometimes spring from the 
ethmoid, and extend into the orbit, and malignant growths may 
be met with here. 

Tumors that spring from the Body of the Sphenoid Bone, or 
from the Antrum of the Sphenoid, and encroach upon the orbit 
are rare, and the diagnosis of their origin in an early stage is 
practically impossible. Here, again, the examination of the 
naso-pharynx is important. It is stated (Stedman Bull) that 
an orbital tumor which soon causes blindness, commencing in 
the temporal side of the field, and leaving the fixation point un- 
affected to the last, while at the same time a growth appears in 
naso-pharynx, is likely to be one having its origin in the sphenoid 
antrum. Bony tumors — osteoma, hyperostosis and extostosis — 
polypi, and sarcomata, are the growths most frequently found to 
originate in the sphenoid antrum. 

Tumors of the Maxillary Antrum sometimes erode the floor 
of the orbit, and grow into that cavity, driving the eyeball up- 
wards and inwards, or upwards and outwards. The breadth of 
the cheek is increased, the nose becomes pushed towards the 
opposite side, and the roof of the mouth is pushed downwards. 
Tumors of the antrum of Highmore sometimes cause pain in the 
teeth, or in the region of distribution of the infra-orbital nerve, 
and there may be a dull pain in the region of the antrum. In 
some cases there is a discharge of pus or of blood from the 
nostril. 

Intracranial Tumors do not often invade the orbit, and then 
it is tumors of the middle fossa which gain access through the 
sphenoid fissure and optic foramen. The diagnosis of the 
origin of the disease can only be made if cerebral symptoms have 
existed prior to any sign of a new growth in the orbit. Tumors 
of the pituitary body may encroach upon the orbit by way of the 
sphenoid fissure, and are apt to be associated with polyuria and 
bitemporal hemianopsia, which serve to aid the diagnosis. 

A more common event, although not in an early stage of the 
growth, is the extension of a primary orbital tumor to the brain 
either along the optic nerve, through the sphenoid fissure, or 
through the roof of the orbit by erosion of the bone. This oc- 



512 DISEASES OF THE EYE. 

currence is usually evidenced by the presence of cerebral symp- 
toms ; but cases have been met w^ith w^here no such symptoms 
existed, although the orbital growth had encroached upon the 
anterior or middle fossa of the skull. 

Tumors of the Lacrimal Gland. — Slov^ly increasing exoph- 
thalmos, the eyeball being gradually pushed forwards and in- 
wards, and its motions curtailed in the upward and outward 
direction, is a constant symptom here. In the region of the 
gland the upper eyelid seems to be swollen ; but palpation shows 
this to be caused by a growth situated behind the lid, and not m 
it, and, further, that the tumor originates in the orbit. The 
upper fornix of the conjunctiva is found, on eversion of the 
upper lid, to be pushed downwards. After a time the blood- 
vessels of the upper lid become congested and tortuous, and 
when the tumor has grown very large the eyelids cannot be 
closed, the eyeball becomes injected, and the cornea dry and 
opaque. 

Adenoma, or Adeno-sarcoma, and Fibro-adenoma are the 
most common forms of tumor of the lacrimal gland, and the 
gland on each side may be affected. 

Extirpation of the growth at as early a stage as possible is 
indicated. The tumor is reached, either through an incision 
made through the lid parallel to the outer half of the upper 
orbital margin ; or, the external commissure having been 
divided, and the upper lid turned up, the growth can be removed 
through an incision made in the conjunctival fornix; or Kron- 
lein's operation (p. 515) may be indicated. 

Tumors of the Optic Nerve. (See p. 436.) 

Hernia Cerebri, either in the form of meningocele or of en- 
cephalocele, may invade the orbit. Its most common situation 
is the upper and inner angle of the orbit, to which it gains access 
through the suture between the frontal and ethmoid bones. It 
appears as a fluctuating, often transparent, pulsating congenital 
tumor. Pressure upon it causes it to disappear, but gives rise, 
at the same time, to symptoms of cerebral irritation, or pressure. 

A congenital tumor in the upper inner angle of the orbit must 
always be regarded with suspicion, lest it be a cerebral hernia, 
even though it do not pulsate, or on pressure cause cerebral 
symptoms. In the large cerebral hernia death in the first few 
days of life is, we know, the rule. 

Shrinking of the Conjunctiva (Xerophthalmos) and of the 



THE ORBIT. 513 

Subconjunctival Tissue of the Orbit, Subsequent to Enuclea- 
tion of the Eyeball. — In some cases where the eyeball has been 
excised, and in due course a prothesis fitted, the conjunctiva and 
subconjunctival tissues shrink to such a degree, after some months 
or years, as to reduce the size of the orbital cavity so that the 
wearing of a glass eye becomes impossible. This is especially 
liable to occur amongst those hospital patients who are careless in 
removing the prothesis at night, and in keeping the socket thor- 
oughly clean at all times. The attempt is then often made to 
restore the orbital cavity, so as to render it possible to wear at least 
a small glass eye, by means of skin grafts or of mucous mem- 
brane grafts after the method either of Thiersch or of Wolf. 
The success attendant on these procedures is usually a very moder- 



ate one, and often not permanent, owing to subsequent renewed 
shrinking of the subconjunctival tissue. 

In these cases the lower sulcus is the most important part of 
the cavity, and if it can be made sufficiently deep, a small artificial 
eye will be retained. With this object in view, Mr. P. W. Max- 
well, of Dublin, has devised the following operation : 

An incision is made in the floor of the socket, and carried 
downwards behind the lower Hd. A semilunar flap, about 8 
mm. in width at its widest part, is marked out on the skin of the 
lid, its upper concave border being about 5 mm. below the pal- 
pebral margin. The incision along the upper border of the flap 
is made to communicate with the bottom of the wound in the 
socket. The flap is now dissected up from the subcutaneous 
tissue, except an area represented by the dotted line in Fig. 159. 
The two ends of the flap {a' and h') are passed through the 

43 



514 DISEASES OF THE EYE. 

opening into the socket, and sutured to each end of the socket 
incision (a and b) ; and the borders A' and B', being also passed 
through, are sutured to A and B respectively. The space on the 
cheek is closed, and the operation completed by inserting into the 
socket a temporary glass eye or shell. This should be, as nearly 
as possible, of the size and shape of the eye to be ultimately 
worn ; it prevents the new sulcus from being obliterated by 
contraction, and gives it a suitable shape. It cannot safely be 
taken out for at least a week, as the skin incision might perhaps 
be opened in so doing. If there be secretion, the space behind 
may be flushed out by a lacrimal syringe armed with a fine curved 
nozzle, which can be introduced under the edge of the eye at the 
inner or outer canthus. A glass shell with a hole in front is 
preferable to a glass eye, for it allows a syringe to be more easily 
used, and, being transparent, a view of the parts behind can be 
obtained. 

To obtain a good result the following points should be attended 
to: 

1. Make the incision in the socket as long as the space will 
permit, and see that this length is maintained throughout its en- 
tire depth. 

2. Make the skin flap considerably longer than the incision in 
the socket. 

3. When dissecting up the skin flap, leave undisturbed a por- 
tion (dotted line in figure) equal in length to the socket in- 
cision. This subsequently forms the fornix, or sulcus. If a 
shorter portion is left, the sulcus is apt to become V-shaped, 
which would require a specially made glass eye. 

4. When closing the space on the cheek, as the lower border 
is longer than the upper, great care should be taken to equably 
distribute the excess, so as to avoid puckering. When this has 
been neatly done, the line upon the face becomes quite invisible 
after a few months. 

In none of the cases, so far, has it been necessary to make a sul- 
cus above. The same operation could, however, be performed 
on the upper lid, provided that, after dissecting up both the borders 
of the skin flap, the tendon of the levator were secured with one 
or two sutures before dividing it. After the skin flap is in its new 
position, the cut end of the levator could be attached to the tarsus. 
In closing the skin wound, the ends of these deep sutures should 
be allowed to project outwards, so that they may be pulled out 



THE ORBIT. 515 

when they ultimately become loose. If it were possible to obtain 
really aseptic catgut, the ends of the sutures might be cut short and 
buried. 

In addition to providing a sulcus, the operation adds half the 
width of the flap — viz., 4 mm. — to the vertical diameter of the 
socket. 

Temporary Resection of the Outer Wall of the Orbit 
(Kronlein's Operation). — This operation was devised by Pro- 
fessor Kronlein,^ of Zurich, for the removal of tumors of the 
optic nerve, and other new growths and cysts in the posterior 
part of the orbit, as well as foreign bodies, without sacrificing 
the eyeball, or perhaps even the sight. It may also be employed 
to reach purulent foci in the orbit, and has been used, with what 
result I cannot say, to remove some of the retrobulbar fat in cases 
of exophthalmic goiter. 

The eyebrow and the scalp in the temporal region are shaved, 
and the skin of the whole region of the operation is rendered 
aseptic. 

The First Stage of the operation consists in making a curved 
incision on the temple through the skin and soft parts. This 
incision commences on the temporal ridge, at a point where the 
latter would be intersected by a horizontal line running i cm. 
above the supra-orbital margin. The middle point, or apex, of the 
incision lies in the center of a horizontal line, which unites the 
external canthus with the outer orbital margin. The end of the 
incision lies on the zygoma, in the center of a horizontal line 
uniting the external canthus with the tragus. The length of the 
incision in adults is 6 to 7 cm., and the direct distance between its 
two ends is about 5 cm. Smaller incisions are inconvenient. In 
that portion of the incision which runs along the margin of the 
orbit it goes to the bone, through the periosteum. 

The Second Stage consists in raising the periosteum from the 
inner surface of the outer wall of the orbit with a slightly curved 
and somewhat pointed elevator, which is introduced at the exposed 
outer orbital margin. The periosteum is separated upwards as far 
as I cm. above the fronto-malar suture, downwards as far 
as the spheno-maxillary fissure, and posteriorly until well behind 
the spheno-zygomatic suture. This proceeding is not difficult, as 
the periosteum is closely adherent along the orbital margin only, 
and at the sutures. The point of the elevator is now passed 
directly downwards, and carefully introduced into the spheno- 



5i6 DISEASES OF THE EYE. 

maxillary fissure a few millimeters behind the spheno-zygomatic 
suture. The handle of the instrument is then turned over gently 
towards the nose, thus pressing the periosteum and all the con- 
tents of the orbit somewhat inwards, and exposing the bared 
inner surface of the outer orbital wall. The object of passing 
the point of the elevator into the spheno-maxillary fissure — 
where it remains during the next stage of the operation — is to 
fix the point towards which the osseous incisions are to be made 
to converge. Some surgeons prefer to omit this act, and the 
proximity of the infra-orbital nerve, and of the infra-orbital 
vessels must be borne in mind. 

The Third Stage is the resection of the bony wall by three 
incisions, two horizontal and one oblique. The upper horizontal 
bony incision is made with a thin, sharp chisel, and divides 
the external angular process of the frontal bone close to its base. 
The soft parts have been previously drawn aside, the periosteum 
over the seat of the proposed bony incision divided and, along 
with the lacrimal gland, drawn aside. 

The oblique bony incision passes from the deepest part of the 
previous incision downwards and backwards behind the spheno- 
maxillary suture, through the greater wing of the sphenoid bone, 
to a point about i cm. behind the anterior end of the spheno-maxil- 
lary fissure, where the point of the elevator has been kept all 
through. 

The lower horizontal bony incision divides the frontal process 
of the malar bone close to its base, the soft parts having been 
drawn aside, and the periosteum divided. The incision ends at 
the anterior extremity of the spheno-maxillary fissure. 

In making the bony incisions there is the danger of splintering 
to be contended with, and in the oblique incision there is some 
danger of luxating the spheno-maxillary suture. The chisel 
must be very sharp and thin, and it is well to apply its corner 
rather than its full edge to the bone, while only light taps with the 
mallet are used. It is important to make the bony incision in the 
above order ; or, at any rate, the oblique incision should not be the 
last to be made, for, if it be, the thin outer wall of the orbit is liable 
to become severely splintered during the chiseling of the second 
bony process. 

The Fourth Stage is the turning backwards of the flap of bone 
and soft parts, and the exposure of the interior of the orbit. It is 
necessary, after the flap has been turned well back, to divide the 



THE ORBIT. 517 

separated periosteum with a blunt-pointed scissors from be- 
fore backwards. It is sometimes necessary, in order to reach the 
focus of disease, to divide the tendon of the external rectus near 
its sclerotic insertion, and possibly other orbital muscles must be 
severed; but this should be avoided, if possible. 

When all manipulations required in the orbit have been com- 
pleted, any muscles which may have been divided are sutured to 
their insertions, the periosteum is replaced in its normal position, 
the flap of bone and soft parts turned forwards into its place, and 
secured there by a few catgut sutures through the periosteum. A 
drain is then placed in the lower part of the wound, and the rest 
of the wound is accurately closed with fine silk sutures, and an 
aseptic dressing and bandage applied. The catgut sutures through 
the periosteum, and the drain, are regarded by several operators 
as unnecessary. The only recorded case of this operation in 
the United Kingdom is one successfully performed by Dr. 
Louis Werner ^ for a tumor of the optic nerve. ( See also p. 

436.) 

Exophthalmic Goiter (Graves' Disease, Basedow's Disease). 

Symptoms. — The three cardinal symptoms of this disease are : 
increased rapidity of the heart's action, which may reach two 
hundred beats per minute ; tumefaction of the thyroid gland ; and 
exophthalmos. Of these the cardiac symptom is the most con- 
stant, and usually the first to appear ; either, or both of the others, 
may be wanting. There is often also great emaciation, with 
outbursts of sweating and diarrhea. A venous murmur may 
be heard in the neck ; and in females there is very commonly 
irregularity or suppression of menstruation. 

The disease has been observed at all ages, but is most com- 
mon in early adult life. 

Von Graefe's Sign is a very early, tolerably constant, and 
almost pathognomonic one ; it consists in an impairment of the 
consensual movement of the upper lid in association with the 
eyeball. When, in the normal condition, the globe is rolled down- 
wards, the upper eyelid falls, and thus its margin is kept through- 
out in a constant relation to the upper margin of the cornea. In 
Graves' Disease the descent of the upper lid does not take 
place, or only in an imperfect manner; and, consequently, when 
the patient looks down, a zone of sclerotic becomes visible between 
the margin of the lid and the cornea. This symptom is often pres- 
ent prior to any exophthalmos, and hence its great diagnostic 



5i8 DISEASES OF THE EYE. 

value. It may also continue after the latter disappears, — although 
it is perhaps more common for it to disappear before the proptosis, 
— and it is not seen, or but very rarely so, in protrusion of the 
globe from other causes. But the sign is not so absolutely pathog- 
nomonic as it was held by von Graefe to be ; for it may be absent 
in Graves' Disease, although very rarely so, in the early stages, 
and it is sometimes present in other diseased states, and even 
in health. 

Stellwag's Sign is also very constant. It is incompleteness and 
diminished frequency of the act of involuntary nictitation. 

This act occurs sometimes only once in a minute ; or several 
rapid nictitations take place, and then a lengthened pause. The 
nictitation each time is incomplete, the margins of the lid not 
being brought together. The result may be that the lower third 
of the cornea becomes covered with pannus vessels, owing to the 
constant exposure ; for even during sleep the eyelids remain par- 
tially open. 

Dalrymple's Sign consists in an abnormal widening of the pal- 
pebral aperture, due to retraction of the upper eyelid. It is this 
gaping of the eyelids which gives the characteristic staring aspect 
to the patient. This sign is often erroneously attributed to 
Stellwag, or is included in his sign. The error is due to the 
fact that in the same paper * in which Stellwag first drew attention 
to what is above described as his sign, he discussed this other 
previously observed sign. According to White Cooper ® it was 
Dalrymple who first pointed out the latter.* 

Probably each of these '' signs " is due to the one cause sug- 
gested by Sharkey ^^ — namely, loss of power in the orbicularis 
rather than overaction of the levator. 

Otto Becker stated that in a majority of the cases spon- 
taneous pulsation may be seen in the retinal arteries, but I have 
only found it sometimes. The vision — unless when corneal com- 
plications supervene — and condition of the pupil are unaffected by 
the disease. In some cases there is an increased flow of tears, but 
most of the patients complain of a dryness of the eyeballs. The 
sensibility of the cornea is diminished. Ulcers of the cornea are 

* Other conditions which produce widening of the palpebral aperture 
or " Staring Eye," are: (i) Orbital Tumor (mechanically). (2) Stimu- 
lation of the Cervical Sympathetic. (3) Cocain (in slight degree, prob- 
ably by reason of 2.— Jessop). (4) Women after child-birth (hysteria). 
(5) In tetanus (spasm of occipito-frontalis). (6) In complete amaurosis. 



THE ORBIT. 519 

not common, but are said (von Graefe) to be more frequent in 
men than in women, although Graves' Disease is more common in 
women. The exposure of the eye and dryness of the cornea are 
the chief causes of ulceration, when it occurs ; but Sattler inclines 
to the belief that it is also largely due to paralysis of the nervous 
supply of the cornea. 

The patients are often hysterical; and even marked psychical 
disturbances have been noted, such as a peculiar and unnatural 
gayety, rapidity of speech, and great irritability ; or, on the other 
hand, extreme depression, and even attempts at suicide have been 
observed ; also loss of memory and inability to make a mental 
effort. The motions of the eyeball have in some cases been de- 
fective — a fact for which the exophthalmos does not account. 
Trousseau's Cerebral Macula is often well marked. 

The Progress of the Disease is, as a rule, very chronic, extend- 
ing over months or years, but liable to fluctuations in the intensity 
of its symptoms. A few cases have been recorded in which it 
became fully developed in the course of some hours or days. 
After a lengthened period, and many fluctuations, the symptoms 
usually slowly disappear. Occasionally a slight permanent swel- 
ling of the thyroid may remain, and very often more or less 
exophthalmos. About 12 per cent, of the cases go from bad to 
worse, and end fatally from general exhaustion, organic disease 
of the heart which may have come on, cerebral apoplexy, hemor- 
rhage from the bowels, or gangrene of the extremities. 

Causes. — Anemia and chlorosis are general conditions very 
often present, as are, also, irregularities of menstruation ; but it is 
probable that the latter should be regarded rather as a con- 
comitant symptom than as a cause. Severe illnesses are recorded 
as having gone before the onset in many cases, and also excessive 
bodily or mental efforts. Great sexual excitement has been 
known to be followed by Graves' Disease, and depressing psychical 
causes are not unfrequent forerunners of it. In many instances, 
however, the patients have been perfectly healthy, and no cause 
could be assigned. 

The Enlargement of the Thyroid is due in the first instance to 
dilatation of its vessels ; but in a late stage hypertrophy of the 
gland tissue may be produced, and increase of its connective tis- 
sue, and even cystic degeneration. The Exophthalmos is due to 
hyperemia of the retrobulbar orbital tissues, as is demonstrated 
by a vascular bruit often present, and the fact that steady pres- 



520 DISEASES OF THE EYE. 

sure on the globe diminishes the protrusion. Hypertrophy of the 
orbital fat may be found postmortem, but is, doubtless, secondary 
to the hyperemia. 

With regard to the nature of the disease, very many theories 
have, from time to time, been put forward, but none is quite sat- 
isfactory, and a discussion of them does not come within the scope 
of this work. 

Treatment. — A principal part of this consists in the careful 
regulation of the patient's general health and functions. Freedom 
from mental anxiety and excitement, regular hours, moderate ex- 
ercise, and change of air are the most important items. 

The fluctuations, which occur in the intensity of the symptoms, 
render it difficult to arrive at definite conclusions with regard to 
the efficacy of remedies, a vast number of which have been 
tried and lauded from time to time. In mild forms of the affec- 
tion, and especially if the anemia be well marked, iron internally 
is beneficial, but in severe cases it has the opposite effect. Quinin 
in moderate doses has been employed with benefit in some cases. 
Trousseau recommended digitalis in large doses, but its effect must 
be watched. The beneficial action of iodid of potassium in ordinary 
goiter has suggested its use in this disease ; but under its influence 
the symptoms are sometimes aggravated, and it is doubtful whether 
they are ever relieved by it. Hulke praised aconite highly, and 
Sir Samuel Wilks has no doubt as to the value of belladonna. 
Ergotin internally has been tried, and with advantage in some 
instances. Sattler warmly recommends a well-regulated hydro- 
pathic treatment, when the patient is not too excitable. Par- 
oxysms of cardiac palpitations, etc., are best combated by ice 
applied to the head, heart, and goiter. The sympathetic theory 
has induced the trial of a galvanic treatment of the cervical sym- 
pathetic. 

Gauthier recommends antipyrin before everything else. Ex- 
tract of the thymus gland has been occasionally employed, and 
with encouraging results. 

Extirpation of the thyroid has been performed in recent years 
with success in some cases. 

The great number of remedies which have been proposed for it 
demonstrate the intractable nature of this disease. Yet a con- 
siderable proportion of the cases do undergo cure, in so far as 
quieting of the heart's action, and reduction, or possibly some- 
times complete disappearance, of the goiter and exophthalmos, are 



THE ORBIT. 521 

concerned. It is common, however, even in the best recoveries, to 
see some exophthahiios remain permanently. 

In cases where the exophthahiios is so great that the cornea is 
exposed even during sleep, it is desirable to perform tarsorrhaphy 
(p. 207), and the same operation is indicated when, the disease 
having subsided, the exophthalmos still remains to a degree which 
gives the patient a disagreeable expression. 

References. 

^ " Dublin Journal of Medical Sciences," 1836. 

^ " Archives of Ophthal.," xxii. p. 98. 

^ " Trans. Ophthal. Soc, U. K.," vol. ix. p. 41. 

* " Klin. Monatsbl. f. Augenheilk.," September, 1893. 

' " Brit. Med. Journal," October 19, 1895. 

'^ " Beitrage zur Klinischen Chirurgie," iv. i ; see also Domela-Nieu- 
wenhuis, " Beitrage zur Klinischen Chirurgie," xxvii. 2. p. 558. 

^ " Trans. Ophthal. Soc, U. K.," vol. xxiii. 

^ " Wiener j\Ied. Jahrbiicher," xvii. p. 25, 1869. See also " Klin. Mon- 
atsbl. fiir Augenheilkunde," 1869, p. 216; and "v. Graefe und Saemisch's 
Handbuch," vi. pp. 955 and 956. 

^ The " Lancet," May 26, 1849, p. 553. 
" " Trans. Ophth, Soc, U. K.," vol. xi. p. 204. 



44 



CHAPTER XIX. 

Part I. — Ocular Diseases and Symptoms liable to accompany 
Focal Disease of the Brain. 

Part 11. — Ocular Diseases and Symptoms liable to accom- 
pany Diffuse Organic Disease of the Brain. 

Part III. — Ocular Diseases and Symptoms liable to accom- 
pany Diseases and Injuries of the Spinal Cord. 

Part IV. — Nervous Amblyopia, or Asthenopia. 

Part V. — Various Forms of Amblyopia. 

Part I. 

OCULAR DISEASES AND SYMPTOMS LIABLE TO 
ACCOMPANY FOCAL DISEASE OF THE BRAIN. 

Hemianopsia (T/yuzo-j;?, half; a, priv.;(^'f:, the eye). This term 
implies a loss of sight in one-half of the field of vision, usually of 
each eye, consequent upon a lesion at the center of vision, at the 
chiasma, or at some point in the course of the visual fibers be- 
tween these two places. It is not used for cases in which one- 
half of the field is lost, owing to disease within the eye itself. 

The line dividing the seeing from the blind half passes vertically 
down the center of the field, as in Fig. i6o. Sometimes this line 
lies a little to one side of the center of the field, so as to admit 
of the latter being included in the seeing part, as in Fig. i6i ; and 
sometimes — although in other respects the dividing line lies in the 
center of the field — the fixation point is circumvented by it, so as 
to leave that point free, as in Fig. 162 ; and probably this is the 
most common arrangement. Tiiis subject will be further dis- 
cussed later on. Again, although rarely, the dividing line may 
have an oblique direction, as in Fig. 163. It is probable that 
such a field as Fig. 163 is due to some peculiar arrangement in 

522 



FOCAL BRAIN DISEASE. 



523 



the decussation of the nerve fibers in the individual case. Fur- 
thermore, cases occur which are properly regarded as hemia- 
nopsia, and yet in which only a sector of one side of the field is 
wanting, as in Fig. 164. Figs. 160, 161, 162, and 163 would be 
called complete hemianopsia, while Fig. 164 would be termed in- 
complete or partial hemianopsia. Finally, if all three visual per- 





FiG. 161. 



ceptions be lost, the hemianopsia is called absolute ; but if only one 
(color) or two (color and form) be wanting in the defective part 
of the field, it is termed relative hemianopsia. The vast majority 
of cases of hemianopsia are absolute. 

Homonymous Hemianopsia is the most frequent form. In 
it the corresponding half — the right half or the left half — of the 
field of each eye is wanting, as in Fig. 165, in which the left side 





Fig. 163. 



Fig. 164. 



of the fields, from the patient's point of view, is blind, implying a 
loss of function in the right half of each retina. 

Temporal Hemianopsia is loss of vision in the outer side of 
each field, in consequence of loss of power in the median half 
of each retina (Fig. 166). It is by no means so common as the 
homonymous form. 

Superior or Inferior Hemianopsia, also called Altitudinal Hem- 
ianopsia, in which the upper or lower half of the field is blind, is 
very rare; and it is doubtful whether Nasal Hemianopsia has 

* Figs. 160, 161, 162, 163, and 164 are diagrammatic representations of 
the left field of vision. 



524 



DISEASES OF THE EYE. 



really been observed, although it has been described. In the 
latter the inner side of the field of one eye only is lost, owing to 
defective function of the temporal side of the retina. 

It w^ill be convenient here to set forth the prevailing views as 
to 

The Arrangement of the Cortical Visual Centers, their relations 





Left Field. 



Fig. 165. 



Right Field. 



to the Retina, and the Course of the Optic Fibers hetmeen these 
two points. 

Pathological anatomy leaves little doubt but that in man the 
visual center is situated on the mesial surface of the occipital lobe, 
rather than in the angular gyrus or elsewhere ; and the evidence 
goes to show that the absolute optical center chiefly occupies the 





Left Field. 



Right Field. 



Fig. 166. 



cortex of the cuneus and of the superior occipito-temporal con- 
volution. 

Henschen,^ as the result of clinico-pathological investigations, 
believes it to be situated in the middle part of the calcarine fissure, 
which lies between these structures ; and that the upper, or cun^ic, 
lip represents the homonymous dorsal retinal quadrants ; while the 
lower, or lingual, lip represents the homonymous ventral quadrants 
of the retina. Vialet,^ on the other hand, thinks that the visual 
center embraces all the mesial surface of the occipital lobe included 
between the occipito-parietal fissure and the lower border of the 
third occipital convolution, and that it extends above and behind 



FOCAL BRAIN DISEASE. 525 

as far as the free border of the hemisphere. The calcarine fissure 
he also regards as of great importance ^ ; and I think, indeed, he 
rather proves than disproves Henschen's view of its midddle 
third being the actual cortical center for vision. 

It is universally recognized that the nerve fibers from the 
homonymous half of each retina, e. g., from the temporal half of 
the right retina and from the median half of the left retina, pass 
wholly through the corresponding optic tract, — in this case the 
right tract, — to the corresponding cortical center for vision (Fig. 

167). 

A case published by Hun,^ in which the left lower quadrant 
in each field was blind, and where the autopsy showed a lesion 
(atrophy) strictly limited to the lowed half of the right cuneus, 
renders it probable that there is in man a correlation between parts 
of the retina and of the occipital lobe, as ]\Iunk had already proved 
to be the case in dogs, and that the optic fibers from the right lower 
quadrant of each retina terminate in the adjacent part of the 
right superior occipito-temporal convolution, the left halves of 
the retina and left optic centers being of course similarly corre- 
lated. If this view be correct, as seems probable from Henschen's 
investigations, it is evident that altitudinal hemianopsia can hardly 
occur as the result of a central lesion, as nothing short of disease 
confined to the lower half of each cuneus would produce it. 

It is now generally believed that relative hemianopsia {e. g., 
color hemianopsia alone) is the result of a lesion of less intensity 
that which causes absolute hemianopsia. Cases of apparently 
pure hemiachromatopsia may, with careful tests, show some dim- 
inution of the form-sense in the half fields which are defective for 
color-sensations. Non-cortical lesions, even at the chiasma, may 
also give rise to hemiachromatopsia. Thus it would seem that the 
color-sense is more easily affected by disease than the form or 
light senses, and that, too, irrespective of the position of the 
lesion in the visual path. 

It is now generally conceded that the macula lutea is specially 
represented in the cortical center. But there are at least two 
very distinct views as to the arrangement of these macular centers, 

* One of the most important cases which has been published in con- 
nection with this question is that of Dejerine and Vialet (Societe de 
Biologic, Paris, December, 1893), in which both eyes became suddenly 
blind, without loss of consciousness or other symptoms. The patient lived 
for a short time, and after death from pneumonia the post-mortem showed 
lesions of the structures bordering the calcarine fissure on both sides. 



526 



DISEASES OF THE EYE. 
L.F. nE 




1-CC 



I'M. 



MI> 



Fig. 167. — Explanation of Fig. 167. 

Fig. 167. — Diagram of Course of Optic Fibers, with the Cortical Centers 
and Relations to Fields of Vision, illustrating one theory of the Mac- 
ular Supply ; according to which the macula is supplied on the same 
plan as the rest of the retina — /. c, each side of it from the cor- 
responding side of the brain. 

F., Right field of vision; L. F., Left field of vision; R. E., Right eye 
(retina) ; L. E., Left eye (retina) ; m. I. and m. l, Macula lutea; O. N. 
and O. N., Optic nerves; Cli., Chiasma; Tr. and Tr., Optic tracts; 



R 



FOCAL BRAIN DISEASE. 527 

R. C. C. and L. C. C, Right and left cortical centers; M. and M., 
Macular fibers ; P. and P., Peripheral fibers. 

1. Lesion of right cortical center = left homonymous hemianopsia, the 

line of demarcation passing round the left side of the fixation point 
in cases of embolism and thrombosis, but through the fixation point 
in cases of hemorrhage {vide infra'). 

2. Lesion of the right optic tract = left hemianopsia, the line of demarca- 

tion passing through the fixation point. 

3. Lesion of the chiasma = bitemporal hemianopsia, the line of demarca- 

tion passing through the fixation point. 

4. Lesion involving fasciculus lateralis only to right eye, causing nasal 

hemianopsia in the right field. 
Diagram 167 also illustrates the fact that, as regards its relation to the 
optic tracts, the field of each eye is divided unequally, and not in 
halves — e. g., the right tract governs about one-third of the field of 
the right eye, while the other two-thirds is governed by the left optic 
tract. 

and as to the course of the macular fibers. These different views 
have been called into existence by the desire to explain the fact 
that in hemianopsia the line of demarcation sometimes passes 
through the fixation point in the field, and sometimes leaves it 
in the seeing half. It seems to me that neither of these theories 
is quite satisfactory, and I regret that I cannot offer one that is 
more so. 

According to one theory, illustrated by Fig. 167, the macular 
region of the retina is invariably supplied on the same plan as 
the rest of the retina — /. e., each side of it from the corresponding 
side of the brain. In order, then, to explain why it is that in 
some cortical lesions the line of demarcation passes through 
the fixation point in the field, while in others it deviates towards 
the blind side, the supporters of this view state that the cortical 
center for the macular region is more richly supplied with 
blood-vessels than the rest of the visual center ; as is the 
macula lutea itself in relation to the rest of the retina. Hence, 
when the lesion is an embolism, or thrombosis, of the ves- 
sels supplying that part of the brain, this special region, by rea- 
son of abundant anastomoses, preserves its functions, and then 
fields as in Fig. 165 are produced. But, if the lesion be a hemor- 
rhage, the macular region of the cortex would be apt to be in- 
volved in the lesion with the rest of the visual center, and loss of 
function in the corresponding half of the macula lutea, with 
the line of demarcation passing through the fixation point, 
results. 



528 DISEASES OF THE EYE. 

According to the other theory, the whole of the macular region 
— and in some instances even more than this — of each retina being 
innervated from each hemisphere, there is an overlapping, as it is 
called, of nervous supply to these retinal regions. Consequently, 
if there be a lesion at the center for vision in one occipital lobe, the 
center for vision in the other occipital lobe being sound, the 
functions of the whole of each macula — or even of more than 
this — of the defective side of each retina will be preserved. Cases 
where, occasionally, in cortical lesions, the line of demarcation in 
the field does go through the fixation point would be accounted for 
according to this theory, by an individual variation in the supply 
of the maculse, which in these instances would be similar to that 
of the remainder of the retinae. 

But any such theory, to be satisfactory, must be capable of ex- 
plaining the phenomenon in question, not only when the lesion is 
in the cortex, but also when the hemianopsia is caused by a lesion 
in the tract or chiasma. Yet an examination of Fig. 167 will 
show that, according to the theory it represents, in lesions of the 
tract (2), or of the chiasma (3), the line of demarcation would 
pass through the fixation point. And, according to the other 
theory, a lesion either at the tract or at the chiasma would al- 
ways cause the dividing line to circumvent the fixation point. 
It happens, however, that with lesions at either of these situations 
the dividing line sometimes passes through the fixation point, and 
sometimes to one side of it. Consequently, I do not think we have 
yet solved the problem of the nervous supply of the macula 
lutea. 

Some ophthalmologists hold that the line of demarcation al- 
ways passes through the fixation point, and that it is merely im- 
perfect fixation on the part of the patient which makes it seem to 
pass round it. This I believe to be an erroneous view ; but there 
are no doubt cases in which it is difficult to determine the ques- 
tion, and where the line of demarcation approaches very close to 
the fixation point. 

The Localization of the Lesion in Cases of Hemianopsia is a 
subject of interest, and, in view of the advances made within re- 
cent years in cerebral surgery, it is of great practical im- 
portance. 

Lesions of the center of the Chiasma injuring the crossed fibers 
produce as their characteristic symptom bitemporal hemianopsia, 
which may be relative at first, beginning, for instance, as a hemi- 



FOCAL BRAIN DISEASE. 529 

achromatopsia, but later on becoming absolute. In some cases 
(basal meningitis, periostitis, hyperostosis) the diseased process 
comes to a standstill, and the bitemporal hemianopsia remains. 
But the disease generally extends to the uncrossed fibers, ulti- 
mately causing complete blindness. Even when the disease is 
non-progressive, central vision is impaired; whereas in homony- 
mous hemianopsia the latter is not always affected. Optic at- 
rophy, often commencing on the inner side of the papilla, is nearly 
always present at some period of the disease. Syphilitic gummata 
may cause transient recurrent attacks of bitemporal hemian- 
opsia. 

In Altitudinal Hemianopsia the lesion must also, as a rule, be 
at the chiasma, encroaching on it from above or below. Sym- 
metrical cortical lesions might, and optic neuritis sometimes does, 
produce it. 

In Nasal Hemianopsia, too, the lesion must be at the chiasma, 
and must be so situated in its outer angle as to involve only the 
fasciculus lateralis of the affected eye. The occurrence of 
binocular nasal hemianopsia is evidently almost impossible, im- 
plying, as it does, symmetrical lesion of the fasciculus 
lateralis of each tract. According to Henschen, a tumor in the 
external angle of the chiasma is apt to affect the crossed 
fibers as well as the uncrossed, and to produce a form of 
bilateral homonymous hemianopsia. Other symptoms which may 
be present in lesions of the chiasma are anosmia, paralysis of 
orbital nerves, and anesthesia of the conjunctiva and cornea. The 
causes are : fractures of the body of the sphenoid, cysts, tubercle, 
tumors, exostoses, distention of the infundibulum of the third 
ventricle, and, most frequently, tumors of the pituitary body. In 
the latter case proptosis, discharge of fluid from the nostril, and 
diabetes may be present. 

Bitemporal Hemianopsia is a very common and early symp- 
tom in Acromegaly, a disease characterized by great hypertrophy 
of the face and extremities, associated with enlargement of the 
pituitary body, and other conditions which are not so constant. 

In Homonymous Hemianopsia — the commonest form of the 
symptom — localization of the lesion is a more difficult matter than 
in any of the other forms ; for here the disease cannot be situated 
at the chiasma, but may be in the optic tract, or in the visual center, 
or anywhere in the lengthened course of the fibers which con- 
nect these two parts. 



530 DISEASES OF THE EYE. 

Can we distinguish a complete and absolute hemianopsia, due to 
a lesion confined to the occipital lobe, from a similar defect in the 
field, due to a lesion in the optic radiations, internal capsule, 
pulvinar, or optic tract? We may conclude that the hemianopsia 
depends upon an occipital lesion, if it be unaccompanied by hemi- 
plegia, motor aphasia, or paralysis of cerebral nerves, as direct 
symptoms ; but be it remembered that one and all of these are 
liable to accompany lesions of the occipital lobe as distant * 
symptoms. 

Aphasia, too, occasionally accompanies right cortical hemi- 
anopsia (i. e., due to a lesion in the left occipital lobe), although it 
is not easy to ofifer a satisfactory explanation of the fact. 

A diagnostic symptom is what is known as negative vision, 
*' vision nuUe " — that is to say, the patient, though he may be aware 
of the loss of half of his visual field, has no sensation of darkness 
in it, and is just as unconscious of the defect as a healthy person 
is of his blind spot. 

Cortical hemianopsia may be a distant symptom. Gowers has 
observed that, at the onset of many attacks of cerebral hemorrhage, 
hemianopsia is present as a distant symptom of very fleeting char- 
acter — so transitory, indeed, that it does not complicate attempts 
at localization ; but I have seen it to last as long as three weeks. 
Except under this condition, distant hemianopsia seems to be rare 
— a fact which enhances the localizing value of the symptom. 

Cortical hemianopsia may be incomplete, inasmuch as the 
homonymous quadrant only of each field may be wanting. The 
explanation of this v/as given when discussing (p. 524) the corre- 
lation of the visual cortical centers to parts of the retina. 

So much for absolute hemianopsia. But the lesion may be such 
as to destroy only the color-sense, without reaching those for form 
and light. Eight cases of hemiachromatopsia are on record. 

* I suggest the term " distant symptom " in preference to those in 
common use — namely, " indirect symptom " and " pressure symptom." 
We cannot assume that these symptoms are less the direct result of the 
lesion than any of the others which are present ; and, in many instances 
at least, it is certain that they cannot be due to pressure. In short, we 
do not yet know what produces these symptoms, — they may be caused 
by inhibition, — we only know that they are the result of interference 
with functions of parts of the brain not involved in the lesion ; and the 
term " distant symptom " conveys this idea — although perhaps not quite 
grammatically — without committing us to any theory. The corresponding 
German term is " Fernwirkung." 



FOCAL BRAIN DISEASE. 531 

Again, the form-sense may be lost in the half field along with 
the color-sense, while only the light-sense is retained. Further- 
more, cases of hemianopsia are on record in which, in part of the 
defect, both the color and form senses were absent, but the light- 
sense present, while in the remainder of the defect all three vsiual 
prceptions were lost. 

It is generally held that all lesions of the Optic Radiations cause 
homonymous hemianopsia, but it has not yet been proved that 
these are all true visual fibers. Henschen indeed believes that 
only a small portion of them can be regarded as visual fibers, while 
Vialet's investigations seem to show that the visual path includes 
the whole of the optic radiations. A lesion here would be distin- 
guished from one in the cortical center by the possibility of hallu- 
cinations of vision occurring in the former and not in the latter ; 
and further, there would not be '' vision nulle " in the hemianopic 
defects from lesion in the optic radiations. Lesions of the pos- 
terior third of the posterior limb of the Internal Capsule (Char- 
cot's " Sensory Crossway ") are still believed by some to cause 
hemianopsia and hemianesthesia of the opposite side of the body ; 
but analysis of clinical cases affords no support to this view, for 
there are no recorded cases which furnish any definite evidence in 
this respect. Yet, anatomically, fibers have been traced from the 
occipital cortex through the optic radiations and internal capsule 
to the basal ganglia, and thence into the optic tract. The fibers 
passing through the internal capsule from the external geniculate 
body are probably reflex fibers simply. 

The symptoms due to lesion of the Primary Optic Ganglia 
(Pulvinar, Anterior Corpus Quadrigeminum, and External Gen- 
iculate Body) have not as yet been ascertained, the clinical evi- 
dence being indefinite. In lesions of the pulvinar alone two typical 
symptoms occur — viz., hemianopsia and athetosis — and sometimes 
hemianesthesia may be present. 

Hemianopsia from lesions of the Optic Tract is characterized by 
the absence of such symptoms as mind-blindness, word-blindness, 
etc., which are apt to occur in cortical affections, and by the pres- 
ence, probably, of other symptoms pointing to a basal lesion. The 
defects in the fields may be relative (hemiachromatopsia) or in- 
complete (only homonymous quadrants being lost). Lesions of 
the optic tract are, of course, apt to implicate the crus cerebri, but 
do not necessarily do so; and then w^e would have hemiplegia of 
the opposite side of the body associated with the hemianopsia. 



532 DISEASES OF THE EYE. 

Symptoms may also be caused by implication of cranial nerves, 
especially of those which supply the orbital muscles. 

Atrophy of the optic nerve, and sometimes neuritis, according 
to the nature of the lesion, are frequently present. 

The characteristic sign which enables us to localize a lesion in 
the optic tract from one elsewhere causing hemianopsia, is the 
Hemianopic Pupil (Wernicke's pupil-symptom). Illumination of 
the amaurotic half of the retina produces a more sluggish reaction 
than when the light is thrown on the sound side, because the lesion 
is on the distal side of the corpora quadrigemina, and, conse- 
quently, the impulse cannot reach Meynert's fibers to be conducted 
to the center for the third nerve (see pp. 303 and 311). It must 
be stated that some observers deny the occurrence of the hemian- 
opic pupil. But, on the other hand, many observers have obtained 
the symptom. A great obstacle in observing it lies in the difficulty 
of concentrating the light on the blind side of the retina without 
allowing it to fall on the good side. If present, this is a valuable 
sign ; but its absence is not decisive, owing to the difficulty of ob- 
taining it. 

Wilbrand * has proposed an aid in deciding whether the seat of 
lesion in a case of homonymous hemianopsia is above the primary 
optic centers (i. e., in the optic radiation or cortex), or in the optic 
tract. He terms this the Hemianopic Prism Phenomenon, and 
states that he has found it of practical clinical value. The patient 
faces a black wall on which a small white mark is made. One 
eye is closed with a bandage, and the patient is directed to look at 
the mark with the other eye. A prism of about 12° or 14° is 
brought suddenly before the eye, its base being so directed that the 
retinal image of the white spot may be thrown on the half of the 
retina which does not see {e. g., if the experiment be performed 
with the right eye, in a case of right homonymous hemianopsia, 
the inner half of the retina being bhnd, the prism must be placed 
opposite the eye with its base inwards). At the same moment the 
surgeon has to observe whether or not the eye makes such a move- 
ment as would tend to bring the retinal image again on the macula 
lutea (e. g., in the example above chosen the motion would be out- 
wards) ; and, again, whether or not at the moment of rapid re- 
moval of the prism the eye returns to its former position. The 
prism must be brought rapidly before the eye, in order that the 
patient may not be able to observe the path of the moving retinal 
image from the macula lutea towards the boundary line between 



FOCAL BRAIN DISEASE. 533 

the seeing and blind halves of the retina. Those cases in which 
the boundary line is at or close to the macula lutea are the most 
favorable for the experiment. If a compensatory movement of 
the eye takes place when the prism is held before it, then the path 
through the optic tract to the nuclear oculo-motor centers is free, 
and the lesion must be situated above these centers, in the optic 
radiations or cortex. On the other hand, if there is no compen- 
satory motion, the path for the movements of the eye from the 
retina to the nuclear centers must be interrupted. The explanation 
of this phenomenon is very similar to that of the hemianopic pupil 
symptom. Although the motions of the eye for the purpose of 
fixing visual objects are not, strictly speaking, reflex motions, yet, 
in each individual they to a great extent become so by long usage, 
and are controlled mainly by the lower rather than by the cortical 
centers. Hence, so long as the path for these motions to the 
nuclear center is uninterrupted, if the retinal image of the visual 
object be thrown by a prism on a non-seeing part of the retina, 
the necessary compensatory motion of the eye will be made to 
bring the image again on the macula lutea. 

The Forms of Diseased Process causing a Lesion of the Optic 
Tract are : syphilitic gummata and syphilitic meningitis ; new 
growths, including tubercle ; softening and hemorrhage are rare. 
Tumors of the optic thalamus, lenticular nucleus, or temporo- 
sphenoidal lobe may also injure the tract by extension or 
pressure. 

The Prognosis for recovery of vision in the defective halves of 
the fields depends, of course, upon the nature of the lesion. But 
recovery is rare, specially in the most common class of cases — 
those, namely, which are due to cerebral apoplexy. 

In Right Homonymous Hemianopsia, wherever the position of 
the lesion may be, a greater difficulty in reading is experienced 
than in left hemianopsia. This is partly due to the fact that we 
read from left to right and that, owang to the defect being on the 
right side, the word immediately following that at which the pa- 
tient is looking cannot be seen at the same moment. Knies offers 
another explanation, namely, that, owing to the right-sided defect, 
there is loss of the fine co-ordinated movements of the eyes to the 
right. 

Alexia{a,priv.; Xs^i?, speech), or Word-Blindness, is the term 
given by Kussmaul to an inability to understand written or printed 
characters, although they and other small objects can be distinctly 



534 DISEASES OF THE EYE. 

seen. Other visual objects are named with ease (no visual 
aphasia). The patient can express his ideas in writing, or write 
from dictation, yet cannot understand what he has just written, 
nor can he copy written or printed words. He does understand 
the meaning of spoken words, and the use of all objects around 
him (no mind-blindness). He can generally recognize individual 
letters with some difficulty. This is '' pure word-blindness," or 
'* subcortical alexia." When combined with inability to write 
spontaneously or from dictation, it is known as " cortical alexia " 
(Wernicke). The condition has been occasionally complicated 
with hemianopsia. In those cases where an autopsy was obtained 
the lesion was found in the left occipital lobe. Word-blindness 
with agraphia or cortical alexia is due, according to Dejerine and 
Wernicke, to a lesion in the center for visual memory for words, 
which, in right-handed people^ is the left angular gyrus, and in- 
ferior parietal lobule. 

Visual Aphasia consists in inability to name objects seen, the 
use of which is known. The objects can be named, if the patient 
be allowed to feel them, even with his eyes closed. A few cases of 
this afifection have been recorded, and in all there was right 
homonymous hemianopsia. Alexia and agraphia sometimes 
coexisted. 

Dyslexia. — This symptom was first described by Berlin.^ In 
a wide sense it belongs to the aphasic group. It consists in a want 
of power on the patient's part to read more than a very few — four 
or five — words consecutively, either aloud or to himself. The 
difficulty is not caused by dimness of sight, nor by pain in the eye 
or head, but simply by an unconquerable feeling of dislike or dis- 
gust, due to the mental effort. After a few words which can be 
well understood have been read, the book is pushed away, and the 
head drawn backwards and turned aside; and then in a moment 
or two the patient may be tempted to repeat the effort, but with 
the same result after a very few words have been read. The symp- 
tom comes on suddenly, and has been usually the first sign of the 
presence of cerebral disease. Although in most of the cases the 
dyslexia disappeared in the course of a few weeks, either perma- 
nently or to recur later on, yet other symptoms soon followed its 
first onset, such as headache, giddiness, aphasia, hemianopsia, 
paralysis of the tongue, hemianesthesia, hemiplegia, twitching of 
the facial muscles, etc. Seven or eight cases are on record, and 
all have ended fatally. The lesion was situated, in all but one of 



FOCAL BRAIN DISEASE. 535 

those cases where an autopsy was obtained, in the neighborhood of 
Broca's lobe. In one case the left hemisphere was normal, while 
the right hemisphere was extensively diseased. 

Amnestic Color-Blindness is a symptom which is most prob- 
ably due to a lesion in the occipital lobe, interrupting the paths be- 
tween the center for vision and the speech center. It has always 
been accompanied by right homonymous hemianopsia. In this 
condition the patient sees colors and can recognize them, and he 
can perform Holmgren's tests, but he is unable to name each color. 

Visual Hallucinations may occur in cases of homonymous 
hemianopsia in the blind side of the field only, being due to irrita- 
tion of the visual-memory center. Homonymous hemianopic hal- 
lucinations, persisting for years without hemianopsia, have also 
been observed. Visual hallucinations also occur very occasionally 
in connection with glaucoma, and of this I have seen an example. 
Hallucinations differ from illusions in that the former are com- 
pletely subjective, while the latter are perverted sensory impres- 
sions. 

Mind-Blindness, also called Optic Amnesia, is a symptom first 
observed by Munk ^ in his experiments upon animals. It consists 
in the loss of power of recognizing objects, while the power of 
seeing them continues. A whip is seen by the animal, but inspires 
no terror ; a tempting morsel is seen, but excites no desire. The 
symptom was caused by destruction of a region situated chiefly in 
the posterior division of the second external convolution of the 
dog's brain. It has also been observed in man. The patient fails 
to recognize the most familiar objects by sight. In a case 
of my own the patient could not recognize his own wife un- 
til she spoke. There are two forms of mind-blindness — the 
cortical and the transcortical. In the former, the lesion is in 
the center for memory; and the patient has lost the power of 
visual imagination, and cannot describe visual objects from 
memory. In the latter, the connecting path between the center 
for vision and the visual memory center is interrupted, and the 
patient, though he can describe an object from memory, is unable 
to recognize it when looking at it. Hemianopsia is present in the 
majority of cases of mind-blindness ; and color-blindness complete 
or hemianopic is not unusual. The lesion has been found in the 
occipital lobe sometimes involving the parietal convolutions. It 
usually consists in hemorrhage or softening and the symptom is 
consequently sudden in its onset ; but it also occurs from tumors. 



536 DISEASES OF THE EYE. 

Exhausting illnesses, by reducing the mental energy, may produce 
a condition of mind-blindness. 

Some authors localize the center for visual memory in the 
angular gyrus, whilst others take for it the whole of the occipital 
lobe, except the cuneus and its neighborhood. 

The localizing value of orbital paralyses has been explained (p. 
466). 

Part II. 

OCULAR DISEASES AND SYMPTOMS LIABLE TO 
ACCOMPANY CERTAIN DIFFUSE ORGANIC DIS- 
EASES OF THE BRAIN. 

There are organic diseases of the brain which are not focal, and 
which, as they attack extensive regions of the brain substance, may 
be called diffuse. Under the same heading may be placed some 
diseased cerebral states which we cannot doubt are organic, al- 
though their pathology is as yet unascertained. I propose here to 
describe the points of ophthalmological interest which accompany 
some of these diseases. 

Disseminated Sclerosis of the Brain and Spinal Cord. — 
Central Color Scotoma is the most usual defect of sight in this 
disease, and in a few cases absolute central scotoma is present. 
Irregular defects in the periphery of the fields — sometimes only for 
color — or regular concentric contraction may be found. These 
defects may be in one or in both eyes ; they most commonly come 
on very rapidly, and they may get better, or, after a time, get quite 
well. Even complete blindness, lasting as long as several months, 
may occur; but permanent complete blindness is rare. The oph- 
thalmoscopic appearances do not always coincide with the state of 
the vision ; for with marked defect of sight the fundus oculi may 
be normal, or the vision may be normal, while the optic papilla 
looks diseased, or both sight and ophthalmoscopic appearances may 
be abnormal. The most common ophthalmoscopic change is a 
not very intense atrophic appearance of the whole surface of the 
papilla, or its temporal third alone may be affected in this way. 
But in these latter cases, where the temporal third alone shows 
atrophy, a central scotoma is not necessarily present, nor are the 
papillo-macular fasciculi in the nerve diseased. In a very few 
cases optic neuritis is present. The ophthalomoscopic changes may 



DIFFUSE BRAIN DISEASE. 537 

be in both eyes or in only one. Hemianopsia has not been noted, 
and therefore the defects of vision are evidently always due to dis- 
ease in the optic nerve, and not in the chiasma or tract. Uhthofif 
has shown that in disseminated sclerosis there may be disease in 
the trunk of the optic nerve, without any abnormal ophthalmo- 
scopic appearances, or defect of sight. Sometimes defects of 
vision and ophthalmoscopic changes precede all other symptoms 
by long periods, or they appear in the very early stages of the 
disease ; but more commonly they do not come on until other 
symptoms have been present for some time. 

Isolated paralyses of orbital muscles, nuclear paralysis, and 
nystagmus are derangements of the oculo-motor apparatus, which 
are liable to be present in disseminated sclerosis. Marked exterior 
ophthalmoplegia is rare ; but the paralyses of nuclear origin of 
which there can be no doubt are loss of conjugate motion to one 
or other side, and defective power of convergence. Nystagmus 
is present in about 50 per cent, of the cases, and is either of the 
ordinary kind or consists merely in nystagmic twitchings, more 
particularly at the extreme lateral positions of the eyeballs. Very 
slight twitchings in these extreme positions are of no import, as 
they occur even in the healthy state. As true nystagmus is an 
uncommon symptom in other diseases of the general nervous sys- 
tem, it is of value in this diagnosis. Nystagmic twitchings, while 
they do occur in other general nervous diseases, are more common 
in disseminated sclerosis than in any other of these diseases. 

Disseminated sclerosis in its early stages is apt to be mistaken 
for hysteria, owing to the presence of such symptoms as transi- 
tory loss of power in limbs, aphonia, convulsive seizures, hysterical 
manner, and so on, and here the eye-symptoms may come to our 
aid. In hysteria the ophthalmoscopic appearances are normal; 
the fields of vision, if deranged, are contracted, central scotoma 
being rare, and when the fields are contracted the color boundaries 
often do not recede in their regular order — the field for red, for 
example, may be wider than that for the other colors. In hysteria, 
again, it may be found impossible to examine the color fields at all, 
all colors being named dark or black ; and finally oculo-motor dis- 
turbances rarely occur. 

Diffuse Sclerosis of the Brain. — In some rare cases of this dis- 
ease headache, vomiting, and double optic neuritis may lead to the 
diagnosis of cerebral tumor, and error in diagnosis which, with our 
present knowledge, it is impossible to avoid, unless there be also 

45 



538 DISEASES OF THE EYE. 

focal symptoms that would point with certainty to a tumor. The 
mistake will not often occur, as the cases here indicated are exceed- 
ingly rare. 

General Paralysis of the Insane. — Derangements of the in- 
trinsic muscles of the eyeball, orbital paralyses, atrophy of the 
optic disc, and mind-blindness are the eye symptoms which may 
be found in this disease. 

The Pupa, etc. — The pupils are usually contracted in the early 
stages, and dilated at later periods. An early symptom is slight 
inequality in the pupils, with somewhat sluggish reaction of th'e 
wider one, and, also at an early period, there is apt to be loss of the 
pupil-reflex to sensory stimuli. Later on the larger pupil does not 
react to light at all, while its fellow does so normally, and sight is 
good. The so-called paradoxical pupil-symptom is an early 
augury of coming paralysis, and consists in this, that when a 
strong beam of light is thrown into the eye with the focal illumi- 
nation the pupil at first contracts fairly well, then dilates slightly, 
contracts again, and after a few such oscillations finally dilates 
widely, although the strong light still shines into the eye. The 
Argyll Robertson pupil is only found in some cases, and then usu- 
ally in the late stages, but it does occasionally present itself in the 
initial stages. Sometimes the pupil is irregular in shape. 

Paralyses of Orbital Muscles. — These are of rarer occurrence 
than paral5^sis of the pupil ; but the third and sixth nerves are 
occasionally paralyzed even in the early stages, and in these 
stages, too, ptosis and transient nystagmus and twitchings of the 
eyelids may be seen. 

Optic Atrophy. — This is rare in general paralysis, and is then 
seen for the most part in the late stages. But it has sometimes 
come on in a very early period, and has even preceded every other 
symptom by several years. 

Mind-blindness occurs in cases of general paralysis, usually in 
the advanced stages. 

Amaurotic Family Idiocy (Sachs ^) or Infantile Cerebral 
Degeneration with Symmetrical Changes at the Macula 
Lutea (Kingdon and Risien RusselP). — This disease occurs in 
children during the first year of life, and most, if not all, of the 
cases recorded, which may number about fifty, occurred in Jewish 
families. Family predisposition is strongly marked, as many as 
five children in a family of seven having been attacked. The 
causes which have been assigned are neurotic taint, blood relation- 



DIFFUSE BRAIN DISEASE. 539 

ship between the parents, and traumatism of the mother during 
pregnancy. SyphiHs does not seem to play any part in the etiology. 
The children are born sound and healthy, and continue to be so 
for some months. They then cease to develop mentally, and 
idiocy is gradually established. At the same time paresis or paral- 
ysis, either flaccid or spastic, of the greater part of the body ap- 
pears, while the reflexes may be deficient or increased. Hyper- 
acusis is often present. A chief and very early symptom of the 
disease is loss of sight, ending in absolute blindness, with certain 
characteristic ophthalmoscopic appearances, and nystagmus and 
strabismus are sometimes present. A slowly increasing marasmus 
leads to a fatal termination before the end of the second year, as a 
rule. Waren Tay ^ first observed the peculiar ophthalmoscopic 
appearances, and Sachs described the clinical history, general 
symptoms, and morbid changes in the brain. The ophthalmoscopic 
appearances are as follows : There is at first no change in the 
optic discs. At the macula lutea in each eye there is a large white 
spot, rather diffuse, with softened edges, and about twice the size 
of the optic papilla. In its center there is a brownish-red, fairly 
circular spot, which contrasts strongly with the white around it. 
This central spot, as Tay says, has not the appearance of a hemor- 
rhage, nor of pigment, but suggests a gap in the white patch 
through which the healthy structures are seen. In short, the ap- 
pearance reminds one of that seen in cases of embolism of the 
central artery of the retina. At a later period, with complete 
amaurosis, atrophy of the optic nerve is found. 

In the brain the diseased appearances consist in degeneration of 
the pyramidal cells of the cerebral cortex. In the pons and 
medulla oblongata, degeneration of the pyramidal fibers and of the 
fillet has been found ; and in the spinal cord, degeneration of both 
the crossed and direct pyramidal tracts was seen. Treacher Col- 
lins found edema of the retina around the yellow spot, and Holden 
discovered disease of the ganglion cells of the retina similar to that 
in the cerebral cortex. The normal absence of the ganglion cell 
layer at the macula lutea, and the fact that it is thickest just 
around the latter, go far to explain the ophthalmoscopic ap- 
pearances. 

Meningitis. — Inflammation of the cerebral meninges, of what- 
ever form, and whether at the base or on the convexity of the 
brain, is liable to be accompanied by optic neuritis. When the 
meningitis is at the base, ocular paralyses, pain or anesthesia of 



540 DISEASES OF THE EYE. 

regions supplied by the fifth nerve, and defects in the fields of 
vision from pressure on the optic tracts or commissure, may be 
found. 

Acute Tubercular Meningitis. — In a small percentage of the 
cases of this form of meningitis miliary tubercles in the chorioid 
are present. Optic neuritis is more common than in any other 
form of meningitis, as are also orbital paralyses, in consequence of 
the tendency of this form to attack the base of the brain. 

Cerebrospinal Meningitis. — Eye-symptoms are often present 
both in the epidemic and sporadic forms of this disease. Swell- 
ing of the eyelids, conjunctivitis, and photophobia are frequent 
even in the early stages. The pupils may be unequal, contracted, 
or dilated. There may be ulceration of the cornea, parenchy- 
matous keratitis, or deep purulent infiltrations. Retinitis and 
plastic irido-chorioiditis, followed by retinal detachment, may be 
found, or there may be purulent irido-chorioiditis, with purulent 
infiltration of the vitreous humor, going on to panophthalmitis. 
If the fundus can be examined, optic neuritis or neuro-retinitis 
will often be seen, or thrombosis of the central vein, with retinal 
hemorrhages. Each epidemic of cerebrospinal meningitis is apt 
to be associated with some one of these conditions as its special 
type of eye-affection. The eye-affections in cerebrospinal menin- 
gitis then are very grave; but some of the cases of irido-chorioi- 
ditis do recover, with retention oi good sight. 

Traumatic Meningitis. — Falls and blows on the head which 
do not fracture the skull are held by many to be capable of causing 
meningitis, and occasionally, the inflammatory process, reaching 
the optic nerve, creeps down it to the optic papilla, where it may 
be diagnosed with the ophthalmoscope. 

Hydrocephalus. — Well-marked papillitis, or neuritic atrophy, is 
sometimes found in congenital hydrocephalus, or in the hydro- 
cephalus which makes its appearance in infancy ; and it would 
probably be more common, but for the compensation for the in- 
creased intracranial pressure, which distention of the sutures and 
fontanels must provide. In the acquired hydrocephalus of later 
life, optic neuritis, passing over the optic atrophy, is the rule ; and 
such cases may closely simulate an intracranial tumor in all their 
other symptoms as well. Bitemporal hemianopsia is apt to be 
present, owing to pressure on the optic commissure by the dis- 
tended floor of the third ventricle. 

Infantile Paralysis. — Hemianopsia has been noted in a very 



DIFFUSE BRAIN DISEASE. 541 

few cases oi[ this affection ; and papillitis, with some orbital paral- 
ysis, has also been seen, but usually there are no eye-symptoms. 

Paralysis Agitans, or Parkinson's Disease. — In some cases a 
fine vibratory tremor may be noticed along the margin of the upper 
lid, especially when the eyes are closed, and the lids will be found 
to be unusually rigid on an attempt being made at passive opening 
of them. The slowness of muscular action in other parts does not 
affect the motions of the eyeballs. If a patient be called on to look 
in any direction, the eyes are instantly turned, while the head 
slowly follows them. 

Encephalopathia Saturnia. — Even in the milder cases, tran- 
sient hemianopsia or amaurosis, which may last for several hours, 
is sometimes met with. There need be no renal disease, and the 
visual defect must be taken as the result of the lead-poisoning on 
the brain. In those cases in which acute cerebral disturbances sets 
in (convulsions, delirium, coma) it is often attended by optic neu- 
ritis, with considerable swelling of the disc, and retinal hemor- 
rhages. 

Sometimes the fields are contracted without ophthalmoscopic ap- 
pearances, as in hysteria. The pupils may be unequal. As head- 
ache, vomiting, and convulsions are symptoms of the more serious 
cases of lead-poisoning, it is evident that when intense optic neu- 
ritis is added, the diagnosis between this disease and cerebral 
tumor has to be considered. The characteristic blue line on the 
gums, anemia, colic, constipation, drop wrist, and lead in the urine, 
are the aids to the diagnosis, along with the previous history, in- 
cluding the patient's occupation. 

Epilepsy. — A visual aura is more common than any other special 
sense aura in idiopathic epilepsy. It may take the form of sub- 
jective sensations of lights, color, flames, megalopsia or micropsia, 
etc. ; or visual hallucinations may occur ; or there may be simple 
homonymous hemianopsia. Where epilepsy is due to organic 
brain disease a visual aura, occurring always in homonymous sides 
of the fields, is important, as indicating the occipital lobe as the 
region of the brain in which the discharge originates. At the 
onset of an epileptic fit there is often conjugate lateral deviation 
of the eyes to the opposite side of the body from that on which the 
convulsions commence, with rotation of the head in the same direc- 
tion, while subsequently the eyes may suddenly be turned in the 
opposite direction. The condition of the pupils vary, often even 
in one and the same fit. At the onset thev are usually normal or 



542 DISEASES OF THE EYE. 

contracted ; but during the tonic spasm they become dilated, and 
remain so until consciousness returns. The pupillary light-reflex 
is lost — a point of importance in the diagnosis of a true epileptic 
fit from an hysterical attack, in which latter it is retained. After 
a fit, rapid changes in the size of the pupil may sometimes be seen, 
and these are valuable as evidence of the fit having been a genuine 
one. The ophthalmoscopic appearances during a fit vary in dif- 
ferent cases. In some they are normal, in others there is marked 
pallor of the disc and contraction of the blood-vessels, and, agam, 
in others the papilla is hyperemic and the retinal veins enlarged. 
Optic neuritis and optic atrophy do not belong to epilepsy ; and if 
found they can be regarded only as complications. Between at- 
tacks the fundus may be normal ; but it is not unusual to find a 
high degree of hyperemia of the retina and papilla, which may 
continue for some days or hours, or may even become chronic. 
The fields of vision after a fit, and sometimes as a permanent state, 
are concentrically contracted ; or there may be color-blindness, and 
the central acuteness of vision may be reduced. The state of the 
fields is a valuable aid in the detection of simulation. Transitory 
amblyopia (migraine, scotoma, etc.) is more frequent in connec- 
tion with epilepsy than under any other condition. It may precede 
the true attack by years, or it may occur with, or for an hour or 
so before, the fits, or it may be substituted for them. Inasmuch 
as this transitory amblyopia is often attended by disturbances in 
speech, in the intelligence, or by passing paralysis, and as both 
eyes are usually attacked by it, frequently in the form of homony- 
mous hemianopsia, it is obvious that its cause resides in the visual 
cortex. Occasionally the blindness is monocular, and must then 
be referred to disturbance in the circulation of the retina or optic 
nerve. It is held by some authorities that, given a predisposition 
to epilepsy, irregularities in refraction may at times prove the ex- 
citing cause of the disease ; and that cases of epilepsy occur, in 
which the attack is induced by the undue strain put upon the mus- 
cular apparatus of the eye by reason of an abnormality of refrac- 
tion. They also hold that, if correcting glasses be worn by these 
patients at a sufficiently early period, the fits will cease, or at least 
in a considerable proportion of the cases. Further investigations 
on this subject are required, especially as concerns the permanence 
of cures. 

Chorea. — It is probable, I think, that in some cases, at least, of 
this affection cerebral embolism may be taken as the cause. Sev- 



SPINAL DISEASE. 543 

eral instances of embolism of retinal vessels have been seen in im- 
mediate connection with the onset of chorea. 

In chorea the eyes participate in the irregular jerky motions and 
the spasm may be so unequal in the two eyes as to cause brief 
diplopia; although, not being constant, it is little heeded by the 
patients, and is rarely mentioned by them. 



Part III. 

OCULAR DISEASES AND SYMPTOMS LIABLE TO 
ACCOMPANY CERTAIN DISEASES AND IN- 
JURIES OF THE SPINAL CORD. 

Tabes Dorsalis. — Amongst the ocular complications to be 
found in this disease Atrophy of the Optic Nerve is the most 
serious. It occurs in about 20 per cent, of the cases, and com- 
mences more frequently in the preataxic period than subsequently. 
Rarely it is the first symptom, preceding all spinal symptoms by 
from two to twenty years, and it does sometimes commence in the 
later stages of locomotor ataxy. Coming on in the preataxic 
stage, optic atrophy seems very often to have, as Benedikt first 
pointed out, a favorable influence on the spinal disease, the spinal 
symptoms already existing becoming ameliorated or disappearing, 
while the further progress of the disease is retarded or averted. 
It is indeed rare for tabetic patients who go blind at an early 
stage of the disease to become ataxic later; but if the ataxy is 
once well marked, it does not improve with a subsequent develop- 
ment of optic atrophy. It sometimes occurs that the onset of optic 
atrophy in one eye precedes that in the other by a long interval, 
even by many years ; but usually the eyes are afifected simultane- 
ously or with a very short interval. The relation between the 
optic atrophy and the spinal disease is not as yet well understood. 
The atrophy is probably merely a manifestation of a diseased 
process in the optic nerve, similar to that which attacks the pos- 
terior columns of the cord. 

Paralysis and Ataxy of the Orbital Muscles. — Paralyses of 
orbital muscles in locomotor ataxy occur in about 30 per cent, of 
the cases. They usually appear in the preataxic stage, and even 
as an initial symptom, and are of two kinds — namely, the transient 
paralysis, which lasts a few days or weeks, and may recur; and 



544 DISEASES OF THE EYE. 

the permanent paralysis of one or two muscles. Diplopia is pro- 
duced by these paralyses, and is often the symptom which first 
induces the patient to see his doctor. The sixth nerve is the one 
most commonly paralyzed ; but the third nerve is also often para- 
lyzed, including the branch to the levator palpebrse, with resulting 
ptosis. Loss of power of convergence is often present in com- 
mencing tabes, and double exterior ophthalmoplegia, as well as 
double sixth-nerve paralysis, is sometimes seen; and there can be 
no doubt but that all these three conditions, and probably also some 
of the other oculo-motor disturbances in tabes, are of nuclear 
origin. But the orbital nerves may, it is found, undergo atrophy 
without their nuclei being altered, and probably, therefore, some of 
the ocular paralyses here are due to peripheral neuritis. 

Ocular ataxy is another not infrequent symptom in tabes. It is 
sometimes erroneously called nystagmus ; but nystagmus is a con- 
stant oscillatory motion of the eyeballs, both while the eyes are at 
rest, and when they are looking at an object, and is extremely 
rare in tabes. In ocular ataxy, so long as the eyes are at rest, 
there is no oscillation or twitching; but as soon as an object is 
carefully looked at, and especially if followed when in motion, and 
more particularly at the end of the latter, a slight twitching of the 
eyeballs is seen. It may be found in any stage of tabes. 

Pupillary Alterations. — Myosis is the usual state of the pupil in 
tabes, and is held to be due to paralysis of the pupil-dilating fibers 
from disease in the front part of the aqueduct of Sylvius. The 
myosis is often extreme, or " pin-hole," as it is then termed ; yet 
the pupil may react to light and on convergence. The pupil may 
be of normal size in tabes ; but mydriasis, except as part of a third- 
nerve paralysis, is rare. Again, both in the early and later stages 
the pupils may be of different sizes. 

The Argyll Robertson pupil is an important symptom of tabes. 
It consists in this, that the pupil, although as a rule contracted, does 
not respond to the stimulus of light by further contraction, or, if 
so, but slightly, yet does become more contracted on convergence 
of the visual axes (or on accommodation). Myosis need not 
necessarily be present with the Argyll Robertson pupil ; the pupil 
may be of normal size or dilated. The symptom is one of those 
most regularly found in tabes. It is often an early or initial symp- 
tom, and it continues through all the stages of the disease. It is 
occasionally present in one eye only, and is sometimes quite want- 
ing. (See also p. 310.) 



SPINAL DISEASE. 545 

Neither the Argyll Robertson pupil nor primary optic atrophy 
occurs in peripheral neuritis, a disease which is liable to be some- 
times mistaken for tabes. 

Paralysis of Accommodation without paralysis of the sphincter 
iridis is a rare symptom in tabes. It is more common in the late 
than in the early stages. 

Narrouing of the Palpebral Fissure, due to a slight drooping 
of the eyehds, hardly to be called ptosis, sometimes occurs in tabes 
along with the myosis. It is held to be due to paralysis of the sym- 
pathetic (sympathetic ptosis), is usually binocular, and the fre- 
quency of its occurrence increases as the disease advances. 

Twitchings in the Orbicularis Muscle for some Moments after 
Closure of the Eyelids may sometimes be observed in tabes. Simi- 
lar twitchings may occasionally be seen in some other nervous dis- 
eases, and even in health, but less well marked. Probably their 
marked character in tabes is due to very slight facial paralysis, 
and the consequent imperfect power of closing the eyelids. 

Epiphora is stated by some authors to be not rare in tabes, but 
others deny this, and I have not myself observed it to be so. 

Reduction of Intra-ocular Tension is a symptom in tabes to 
which as yet Berger alone has drawn attention. He found it 
present in thirty-five out of one hundred and nine cases examined. 
Hereditary Ataxy (Friedreich's Disease) has few eye-symp- 
toms, a fact of some diagnostic importance. Ataxic nystagmus, 
as Friedreich pointed out, is the only one which occurs with any 
constancy. Optic atrophy is of such rare occurrence in the dis- 
ease that it can hardly be reckoned as one of its symptoms. 
Paralyses of orbital muscles do not occur, nor does any pupil- 
symptom. 

Myelitis. — Apart from the inflammation of its meninges (cere- 
brospinal meningitis), of which I have already spoken, acute 
inflammation of the cord may be associated with optic neuritis. 
The optic nerve seems usually to become inflamed before the 
spinal cord, but the myelitis may precede the optic neuritis, or 
optic nerve and spinal cord may be simultaneously attacked. The 
relation of the optic neuritis and myehtis to each other is, doubt- 
less, nothing more than that each is a manifestation of the presence 
in the system of one and the same toxic influence, whatever it 
may be. Rheumatism, epidemic influenza, and syphilis are 
amongst the causes assigned in some cases, while in others no 
cause could be assigned. If the cervical portion of the cord is in- 

46 



546 DISEASES OF THE EYE. 

flamed, pupillary symptoms — irritation mydriasis or paralytic 
myosis — are apt to be present. 

Syringomyelia and Morvan*s Disease. — One eye-symptom is 
common to both of these diseases (which are, indeed, held by many 
to be one and the same disease) — namely, a concentric contraction 
of the field of vision without ophthalmoscopic changes. It is not 
quite certain whether this abnormality of the field is due, at least 
sometimes, to attendant hysteria, or is always a symptom of the 
organic disease as such. Inequality of the pupils has sometimes 
been noted. 

Myotonia Congenita (Thomson's Disease). — In some cases 
of this rare disease the external musculature of the eyes affords 
symptoms, although the intrinsic muscles are never disordered. 
The opening and closing of the eyelids may be difficult — they can- 
not be closed or opened at one stroke, successive jerky motions 
being required to effect closure or opening. As in Graves' dis- 
ease when the eyes are open the upper lid is apt to be retracted, 
and the upper lid does not readily follow the downward motions 
of the eyeball. Transitory amblyopia, or even amaurosis, has been 
noted in some cases. 

Acute Ascending Paralysis (Landry's Disease). — Eye-symp- 
toms are rare in this disease, but there may be paralysis of some of 
the orbital muscles, paralysis of accommodation, mydriasis, or loss 
of the light-reflex. 

Injuries of the Spinal Cord. — The condition which used to be 
known as railway spine, but which is now better styled traumatic 
neurosis, and is due to mental shock rather than to organic lesions 
of the brain and spinal cord, is accompanied frequently by certain 
functional eye-symptoms of which the chief one is a contraction of 
the field of vision similar to that found in some cases of hysteria. 
In those much rarer cases of organic injury to the cord, or of 
myelitis, or of hemorrhage in, or inflammation of, its membranes, 
following on railway and other accidents, organic eye-disease sel- 
dom results, although optic neuritis and optic atrophy used to be 
held to be frequent consequences of these injuries. If the lesion 
be in the lower cervical region of the cord, the pupils are apt to be 
contracted from sympathetic paralysis. 



NERVOUS AMBLYOPIA. 547 



Part IV. 

NERVOUS AMBLYOPIA, OR NERVOUS 
ASTHENOPIA. 

We find Nervous Amblyopia, or Nervous Asthenopia, for the 
most part in connection with three functional disorders of the 
nervous system — namely, Neurasthenia, Hysteria, and Traumatic 
Neurosis. Many observers, it is true, hold that these three con- 
ditions ought to be regarded and treated of as hysteria, that the 
term neurasthenia is quite superfluous, while traumatic neurosis is 
merely hysteria caused by shock. This is not the place to enter 
into a discussion on this question ; and it need only be said that 
while these various states of the nervous system are admitted on 
all hands to have much in common, and also to merge insensibly 
into each other, yet typical cases of each are sufficiently differen- 
tiated to make it justifiable, and convenient, for the present, to re- 
tain all three in our minds, as separate clinical entities. 

It may in general be stated that Neurasthenia is abnormal sus- 
ceptibility of the system to fatigue from mental or bodily exer- 
tion ; while in hysteria the symptoms depend upon idea, the 
essence of hysterical conditions being that ideas too easily excite 
abnormal changes in the organism. 

The defects of vision which accompany these disorders are, like 
all their other symptoms, purely functional — /. e., they do not de- 
pend on any organic disease in the retina, or other portions of the 
visual apparatus, but merely upon derangement of the functions 
of these parts. Consequently, there are no ophthalmoscopic 
changes in the fundus oculi. 

In the following, the derangements of vision most liable to be 
found in each condition will be pointed out, but here it is desirable 
in the first instance to state them in a general way. Complete 
blindness of one or both eyes may be found, but is rare ; a dimin- 
ished, but fluctuating, acuteness of vision is more common, the 
eflfort or desire to see well being often the signal for the acuteness 
of vision to fail, and objects disappear from sight if looked at long. 
Attacks of defective sight, too, may come on suddenly without 
any provocation, accompanied by positive scotomata, and may 
last for some minutes. But the most remarkable, important, and 
characteristic symptom is concentric contraction of the fields of 



548 DISEASES OF THE EYE. 

vision. It is almost always necessary, in order to ascertain the 
presence of this symptom, to examine the fields with the perimeter 
— no rougher method will answer — and it is most important to use 
a test-object of not more than 5 mm. square. Concentric con- 
traction of the field is, we know, a symptom in optic atrophy and 
in glaucoma; but, while in those diseases the contraction usually 
advances with more or less deep re-entering angles directed 
towards the fixation point, in nervous amblyopia the contraction 
is about equal in degree in each meridian, and hence the seeing 
portion of the field which is left presents a somewhat circular 
shape. This shape of the field with normal ophthalmoscopic ap- 
pearances is pathognomonic of the condition. The contraction 
may be but slight, or it may approach to within 10° or 5° of the 
fixation point. It is almost invariably present in both eyes; but 
it is often much more marked in one eye than in the other. 

Associated sometimes with this concentric contraction, and 
sometimes without it, is a phenomenon known as the fatigue field. 
It consists in this, that if the test-object be brought from the 
periphery towards the fixation point in each meridian successively, 
it will be found that the outside limit of the field is nearer the fixa- 
tion point on each successive meridian examined, without regard 
to the part of the field in which the examination is commenced. 
Or, if the test-object be brought in the horizontal meridian from 
the periphery on, say, the temporal side across the field until it 
disappears on the nasal side^ and the points of entrance and of 
exit noted, and the object be immediately carried back on the 
same meridian until it disappears on the nasal side, and the en- 
trance and exit again noted, and this maneuver repeated five or 
six times ; should fatigue be present, it will be shown by the points 
of entrance and exit coming nearer and nearer to the fixation point 
on each journey — in short, the field is becoming more and more 
contracted. This method of taking the field in these cases has 
been proposed by Wilbrand, and is useful, too, as showing 
whether at the beginning there is any concentric contraction of 
the field. 

These two modes of examination are practically the same ; and 
the reason for the form of fields they are intended to bring out is 
that the longer in each case the examination is continued the more 
fatigued does the nervous visual apparatus (be it cerebral center, 
or retina, or both) become, and this exhaustion is most marked in 
the periphery of the field. In the normal state the boundary of 



NERVOUS AMBLYOPIA. 549 

the field is not much affected by the length of the examination. 
Ring-form and island-like defects in various parts of the field, 
and which come and go, are recognized as functional defects, and 
cannot be confused with the continuing central scotoma of toxic 
amblyopia due to disease in the papillo-macular fibers. In addi- 
tion to the defective sight, or contraction of the fields, or fleeting 
scotomata, there are often other eye-symptoms present, such as 
weakness of accommodation, or of the internal recti, or some de- 
rangement of the fifth or facial nerves. 

While functional derangements of vision, as distinguished from 
those due to organic disease, are what are here under considera- 
tion, yet it is very necessary to mention that visual defects due to 
organic disease may sometimes be aggravated by functional blind- 
ness. In tabes with optic atrophy, for instance, the contraction 
of the field may become suddenly increased with the occurrence 
of some mental worry or intercurrent general illness, and become 
restored again to its former dimensions with the return to a calmer 
state of mind or to improved health. In homonymous hemian- 
opsia there is often a peripheral contraction in the seeing side of 
the field, which can only be due to diminished functional activity 
in the opposite side of the brain from that in which the disease is 
situated. 

In the three disorders of the nervous system mentioned, the 
symptoms may in a given case remain confined to the nerves which 
are associated with the various functions of the eye ; but this is 
rare. It is more common to find also symptoms provided by the 
derangement of functions in other parts of the nervous system. 

Nervous Amblyopia in Neurasthenia. — School-children and 
those of that age are very liable to become neurasthenic. They 
are brought to the physician with the complaints that the sight is 
confused, that print disappears as they look at it, that reading 
causes the eyes to smart and run with water, and that it brings on 
headache. If the patient be required to read aloud he soon stops, 
complaining that the words are running into each other, and the 
book is then brought closer to the eyes ; then a few more words 
are read, and the book is brought still closer, until, finally, it is 
nearly in contact with the nose; and then further attempts to see 
are made by twisting the head about, turning the book towards 
the light, frowning, and so on. Obviously what causes this diffi- 
culty in reading is a rapid exhaustion of the accommodation. In- 
sufficiency of the internal recti is also often present, and would 



5 so DISEASES OF THE EYE. 

contribute to the difficulty of use for near work. The eyes are 
often emmetropic, and the ampHtude of accommodation is normal. 
Examination of the fields will often discover them to be concen- 
trically contracted, and the fatigue field, too, is frequently present. 
With these asthenic symptoms there are often symptoms of 
exalted sensibility of the visual apparatus, such as photopsiae 
(bright spots, colored balls, glittering surfaces, etc., before 
the eyes), a prolonged continuance of the after-images of 
objects, increased sensitiveness to daylight, and still more so 
to artificial light, and visual hallucinations (heads, animals, 
passing shadows, etc.). In the neurasthenia of school-children 
eye-symptoms often predominate, but other nervous symp- 
toms are nearly always present, such as hallucinations of 
hearing, states of uncalled-for joyous excitement, or of mental 
depression, or of irritability of temper. Vertigo, a tendency to 
weep, some loss of memory, and insomnia may all, or any, of 
them be present. The patellar reflex is usually increased. 
Patches of diminished sensation may be found here and there over 
the surface of the body, although completely anesthetic patches, 
or hemianesthesia, are rare. 

In school-children complaints of difficulty in reading suggest 
malingering in many instances, but it is not wise to adopt this 
view without good grounds for it. An examination of the fields 
may set the question at rest, for neither the concentrically con- 
tracted field nor the fatigue field can be malingered. 

The neurasthenia of adults manifests itself, so far as eve- 
symptoms are concerned, less in the use for near work than is the 
case with school-children. In them, moreover, the contraction of 
the fields is usually slight, while the fatigue field is well-marked. 
These^ patients come complaining of unpleasant and painful sensa- 
tions in and around the eye, such as creeping sensations and bor- 
ing pains in the orbit, stabbings in the eyeball, a sensation as if 
the eye were turned round in the head, uneasy feelings attending 
the motions of the globe. The eye may be very painful on 
pressure at some one spot without apparent cause ; and there are 
often lu^comfortable sensations of cold, burning, or dryness under 
the lids. If there be an error of refraction it is difficult to find 
glasses with which the patient will be content, the bridge and 
winsrs of the frames annoyino: them with their slisrht pressure, 
while the reflection of light from the margins of the eye-pieces 
causes dazzling. The patients are very sensitive to any bright 



NERVOUS AMBLYOPIA. 551 

light. The central acuteness of vision is usually normal, but use 
of the eyes for near work causes headache, often in the form of a 
hammering in the temples, or a sensation of pressure on the 
vertex. 

Treatment. — Tinted protection spectacles. Abstinence from 
use of the eyes for near work. A general tonic treatment, includ- 
ing cold sponge baths when they can be borne, bracing air, plenty 
of exercise in the open air short of fatigue, early hours, and easily 
digested diet. As regards drugs, strychnin and iron are those 
from which most can be expected. 

Nervous Amblyopia in Hysteria. — Nervous amblyopia, or 
nervous asthenopia, in hysteria is often very similar to that in the 
neurasthenia of school-children, except that the difficulty for near 
work is even greater. Tonic blepharospasm and partial paralysis 
of orbital muscles may accompany it. The field of vision is com- 
monly more contracted in one eye than in the other, or the con- 
traction may be very marked in one field, while the other field is 
normal or nearly so. In neurasthenia the contraction is usually 
about equal in each eye. Orientation is rendered more difficult 
by the hysterical than by the neurasthenic field. A high degree of 
blindness, or even complete amaurosis, may attack a neurasthenic 
school-child for a few minutes ; but in hysteria such attacks, 
which may occur in both eyes, but are usually confined to one eye, 
are likely to last for weeks, or months, or longer. In the ambly- 
opia of hysteria, we may find that an eye which cannot see 
moderately sized type is enabled to do so by placing any plane 
glass as spectacles before the eye. Such an occurrence by no 
means proves that the patient is malingering; it shows, rather, 
that the psychical inhibition to the function of sight in the eye has 
been withdrawn by the suggestion provided by the spectacles. 

With monocular amblyopia or amaurosis, there is usually 
hemianesthesia of the same side of the body as the blind eye ; or, 
if there be merely contraction of the fields, there is often hemian- 
esthesia of the side of the most contracted field. 

The pupils vary much in these cases, and even in one and the 
same case from time to time. They may be normal, or wnde and 
immovable, contracted, or of different size in each eye. 

Nervous Amblyopia in Traumatic Neurosis. — In traumatic 
neurosis, one of the most important and most constant of the 
symptoms is concentric contraction of the field of vision. Yet it 
is often absent, and, when present, is not always sufficiently typical 



552 DISEASES OF THE EYE. 

in form to enable it to be utilized in the diagnosis. It is not often 
so pronounced as to interfere with orientation, and must be sought 
for with the perimeter to determine its presence. The boundaries 
for the color-fields are affected even more than that for white, and 
consequently the tests for these boundaries may discover the con- 
traction more readily than exarnination of the boundary for white. 
The relative position of the color boundaries is seldom altered, 
and color-blindness is seldom present. The defect in the field is 
usually to be found in both eyes, and if there be hemianesthesia it 
is on the side of the most contracted field. It is an important fact 
that the contraction of the field may be the only derangement of 
sensation, either special or general. The contraction is liable to 
continue for months or years, and to become more marked for a 
time, as the result of any passing mental disturbance. The fatigue 
field, too, is present in some cases of traumatic neurosis. 

As regards other ocular symptoms in traumatic neurosis : the 
pupil-reflex is usually normal, but is occasionally wanting, and a 
difference in size of the pupils may sometimes be noted ; paralyses 
of orbital muscles are rare, but insufficiency of the internal recti 
is not uncommon ; sensations of sparks, colors, and waviness be- 
fore the eyes are sometimes complained of; photophobia, and sen- 
sations of dazzling with their resulting blepharospasm, may be 
present. 

It is not desirable to rest content with one examination of the 
field of vision which may prove negative in its result, for it is only 
shown thereby that on that particular occasion the field was nor- 
mal. At a later period a defect may be found. 



Part V. 
VARIOUS FORMS OF AMBLYOPIA. 

Transitory Hemianopsia, or Scintillating Scotoma. — This af- 
fection is characterized by ( i ) symmetrical defects in the fields of 
vision, usually of the hemianopic type, and (2) vibrating or scin- 
tillating luminous sensations, which after a short time disappear, 
and are followed by an attack of (3) migraine. In fact, the visual 
troubles belong to the symptoms of migraine. 

The scintillations and defects in the fields, either of which may 
occur first, commence over a small area, generally near the center 



VARIOUS FORMS OF AMBLYOPIA. 553 

of the field, and gradually widen out ; the flashing increases in in- 
tensity, and often assumes a zigzag shape, like fortifications, at the 
periphery of the defect in the field. And this defect may exist as 
symmetrical scotomata, complete or partial homonymous hemian- 
opsia, or even altitudinal hemianopsia. In some cases the scintil- 
lation may be absent, while in others the attack of migraine does 
not follow. The ocular symptoms, which last from a period vary- 
ing from a few minutes to half an hour, are not accompanied by 
any changes in the fundus oculi, and always end in complete re- 
covery. Vertigo, nausea, or sickness, and even slight aphasia 
sometimes accompany the headache. 

This affection occurs most frequently in intellectually active 
individuals; fatigue, long reading, and hunger have been known 
to bring on attacks. The symptoms are most probably due to dis- 
turbances in the cerebral circulation. 

Treatment should be directed to the cause of the migraine. 
Lying with the head low, or stimulation of the circulation by wine 
or nitro-glycerin, sometimes cuts short an attack. 

Congenital Amblyopia. — This condition is not very uncom- 
mon. Ophthalmologists, in the course of their practice, come 
across people in whom the vision of both eyes is below the normal 
standard, even with perfect correction of any error in refraction, 
and who declare that they never have seen better, and that their 
sight is not getting worse. Still more common is congenital 
amblyopia in one eye. As a rule the field of vision and the color- 
vision are normal, but cases are seen in which there is contraction 
of the field, with defective color-sight. 

The Ophthalmoscopic Appearances are normal. 

Reflex Amblyopia is said to have been observed, and chiefly in 
connection with irritation of the fifth pair, especially its dental 
branches ; but I have not seen these cases, and I am rather skeptical 
as to their occurrence. Carious molar teeth are reputed to be its 
frequent cause, usually with severe toothache, but sometimes with- 
out it. The defect of vision may be confined to the side of the 
carious tooth, and is nearly always most marked on that side. It 
is said that it may be of extreme degree, vision being reduced even 
to the merest perception of light. 

More generally recognized than amblyopia, as the result of 
toothache, are: hyperesthesia of the retina, photophobia, sub- 
jective sensations of light, and diminution in the amplitude of 
accommodation. 



554 DISEASES OF THE EYE. 

All these symptoms, even amblyopia of the severest type, dis- 
appear when the dental affection is relieved. 

Many cases are on record in which wounds of the supra-orbital 
nerve were looked on as the cause of amblyopia or of amaurosis ; 
but it is by no means certain that an ophthalmoscopic examina- 
tion would not have afforded another explanation in many of these 
cases. Yet even nowadays many hold that wounds of the supra- 
orbital region can produce amblyopia, as cases are said to have 
been cured by division of the nerve involved in a cicatrix that was 
tender on pressure. 

Sympathetic Irritation (p. 266) is to be included under this 
heading. It is seen in the sound eye in some cases of cyclitis, and 
must not be confounded with sympathetic ophthalmitis, which 
comes about in quite a different way. Its symptoms are : diminu- 
tion of the amplitude of accommodation, asthenopia, hyperesthesia 
of the retina, lacrimation, and subjective appearances of light. 

Removal of the exciting eye, if otherwise indicated, always re- 
lieves sympathetic irritation ; but where this is not admissible the 
dark room, atropin, dry cupping at the temple, with bromid of 
potassium internally^ may be employed. 

The Ophthalmoscopic Appearances in reflex amblyopia are 
normal. 

Night-Blindness. — This is a well-recognized symptom of the 
disease known as Retinitis Pigmentosa (p. 407). I have seen an 
instance of congenital night-blindness in five members of a family 
of ten children without ophthalmoscopic signs ; and Richter, 
quoted by Lawrence, observed a similar instance. But the con- 
dition of which I have here to speak is Acute, or Idiopathic, Night- 
Blindness. 

The patients can see well in good daylight ; but on a very dull 
day, or in the dusk of evening, or by indifferent artificial light, 
their vision sinks very much more than that of persons with nor- 
mal eyes. They are then unable to see small objects, which are 
quite plain to other people, and in a still worse light they fail even 
to recognize large objects visible to everyone else. This peculiar 
visual defect is due to imperfect adaptation power of the retina, 
and not to defective light-sense, as is sometimes stated. 

Conjunctivitis and xerosis of the conjunctiva are often present 
in acute night-blindness (p. 125). Some observers have found 
micrococci and bacilli in the conjunctiva in these cases, and have 
regarded these organisms as the cause of the conjunctival affec- 



VARIOUS FORMS OF AMBLYOPIA. 555 

tion. It seems now more probable that they are merely second- 
ary to the xerosis. 

The connection between night-blindness and xerosis con- 
junctivae remains to be explained; but it is likely that they are 
both results of the one cause. 

Acute night-blindness is often the result of long-continued daz- 
zling by very bright sunlight, or of lengthened exposure to bright 
firelight (e. g., in foundries), and it is probable that in many, if 
not in most, instances of this affection, defective nutrition of the 
system plays the chief role in rendering the patients liable to it. 
Thus, in scorbutus, acute night-blindness has been frequently 
seen, when the patients have been exposed to strong glares of 
sunlight. 

Treatment consists in protection from light, — in short, in com- 
plete darkness for a time, — and then gradual return to ordinary 
daylight ; while the system is to be strengthened by careful dietary 
and suitable tonic medicines. 

Uremic Amblyopia. — This is most commonly seen in connec- 
tion with the nephritis of pregnancy and scarlatina, but may occur 
in any case of uremic poisoning. It is met with in the acute forms 
of nephritis, in which albuminuric retinitis is not so liable to occur. 
The blindness is usually absolute, and may come on suddenly or 
with a short previous stage of dimness of vision. It lasts from 
twelve hours to two or three days, and may recover completely, 
but in some cases a central scotoma remains. 

The Ophthulmoscopic Appearances are negative. 

Treatment can only be directed to the general condition. 

The Prognosis for vision is good, as it always recovers if the 
patient's life be spared. 

Pretended Amaurosis. — Malingerers rarely pretend total blind- 
ness of both eyes, and such cases can often only be detected by 
constant observation of their actions. 

Presence of pupillary reflex is no proof that the patient sees, 
for this would be quite compatible with a cortical lesion causing 
total loss of sight (p. 312). 

The crossed diplopia test {vide infra) may be employed in these 
cases ; for if both eyes see, the one with the prism will rotate in- 
wards for the sake of single vision, while if both eyes be blind, of 
course no such motion will take place. Again, if the malingerer's 
own hand be placed in various positions, and he be asked to look 
at it, he will in all probability look in some other direction ; whereas 



556 DISEASES OF THE EYE. 

a truly blind man usually makes a fair attempt at directing his 
eyes towards his own hand. 

Pretended monocular amaurosis can generally be detected by 
the Diplopia Test. If the malingerer be made to look, with both 
eyes open, at a lighted candle placed some feet off, while a prism 
with its base downwards is held before the admittedly good eye, 
he will say he sees two images of the light one over the other. 
Were he blind of one eye he would not see two images. 

Another method — the Crossed Diplopia Test — consists in hold- 
ing a prism of some io° or 12° with its base outwards before ihe 
pretended blind eye, when, if it sees, it will make a rotation in- 
wards for the sake of single vision, an effort which a blind eye 
would not make. 

Alfred Graefe's Method. — In this test the pretended blind eye 
is covered with the surgeon's hand from behind the patient, while 
with the other hand a prism (about 10°) is held base down before 
the good eye, so that its edge may pass horizontally across the 
center of the pupil. Monocular double vision results, as the rays 
pass through the upper part of the pupil normally, while through 
the lower part of it they are refracted downwards by the prism. 
The double images stand over each other. If now the hand which 
excludes the pretended blind eye be rapidly removed, while at the 
same moment the prism is moved upwards, so that the entire pupil 
is covered by it, a malingerer will still see double images standing 
one over the other ; for now the diplopia must be binocular. 

Harlan's Test consists in placing a trial frame on the patient's 
nose with a very high -j- lens — say -{-14 D — opposite the good 
eye, by which means it is excluded from distant vision, and a plane 
glass — or a 0.25 D convex or concave lens, which of course would 
not materially interfere with its distant vision — opposite the pre- 
tended blind eye. The patient then, believing there is much the 
same kind of glass before each eye, will read the test-types ; and 
if it be now desired to expose the deception, the pretended blind 
eye is excluded from sight, and the malingerer will then be unable 
to read the test-types. 

Snellen's Colored Types may also be used for this purpose. 
These types are printed in green and red. If a person be really 
blind of one eye, he will, of course, see both the green and the red 
letters with the good eye. But if a green glass be held before the 
good eye, the rays from the red letters will be excluded, and he 
will now only see the green letters ; or with a red glass the red 



VARIOUS FORMS OF AMBLYOPIA. 557 

letters alone will be seen. A malingerer may be detected by hold- 
ing before his admittedly good eye a green glass ; and if he now 
still see the red letters, it must be that he does so with the so- 
called blind eye. 

It is well to have this variety of tests, in order that they may be 
used to corroborate each other. 

Krythropsia (Spv^^po?, red) — Red Vision. A large number of 
cases of this remarkable affection are on record; indeed, it will 
have come under the notice of nearly every ophthalmic surgeon of 
any experience. Two- thirds of the cases have been subjects of 
successful cataract operations, whilst the remainder have pos- 
sessed normal eyes. In some cases the red vision remains only a 
few minutes, and does not again return ; whilst in others it appears 
every day for a short time, for weeks or months ; and, again, in 
others it continues for several days, and then disappears for good 
or recurs at intervals. In the aphakic cases it does not usually 
appear for weeks or months after the removal of the cataract, and 
in one case the interval was two years. During the attacks the 
patients see all objects of a deep red color, and occasionally of a 
purple or violet hue. In no instance is the acuteness of vision 
affected either during or after the attacks. 

A satisfactory explanation for the affection has not yet been 
offered. It seems probable that it is due to overexcitation of the 
visual nervous apparatus — some believe of the visual center, others 
of the retina — set a-going by exposure of the retina to strong light, 
along with other favoring circumstances, especially general over- 
excitement of the body or mind. More than this cannot at 
present be said. Why aphakic eyes should be so much more liable 
to erythropsia than eyes which possess their crystalline lenses is 
an enigma. 

Treatment seems to have but little effect. Protection of the 
eyes from light has not been of use. Bromid of potassium inter- 
nally seems to have done some good in those cases where it was 
tried. 

References. 

* " Klinische und Anat. Beitrage zur Pathol, des Gehirns." Upsala, 
1890-92. 

^ Vialet, " Les Centres Cerebraux de la Vision." Paris, 1893. 

^ " American Journal of the Med. Sciences," January, 1887. 

* " Zeitschrift fiir Augenheilkunde," i, p. 125. 

^ *' Archiv. f. Psych.," vol. xv. p. 276, and in his monograph, ** Eine 
besondere Art der Wortblindheit (Dyslexie)." Wiesbaden, 1887. 



558 DISEASES OF THE EYE. 

*"' "Zur Physiologic der Grosshirnrinde," " Archiv f. Anat. und Physiol.," 
V. and vi. pp. 162 and 547. 

' " Journal of Nervous and Mental Disease," 1887, p. 541 ; and " New 
York Medical Journal," May 30, 1896. 

^ " Trans. Med. Chir. Soc," Ixxx. 

• " Trans. Ophthal. Soc, U. K.," i. p. 55, iv. p. 15'S. 



APPENDIX I. 

HOLMGREN'S METHOD FOR TESTING THE COLOR-SENSE. 

For the purposes of this method a selection of BerHn worsteds is 
made, inckiding red, orange, yellow, yellow-green, pure green, blue- 
green, blue, violet, purple, pink, brown, gray ; several shades of each 
color being present, and at least five gradations of each tint, from the 
deepest to the lightest. Green and gray, several kinds each of pink, 
blue, and violet, and the pale gray shades of brown, yellow, red, and 
pink must be well represented. But no two samples are to be of 
precisely the same shade of the same color. This large number of 
colors and shades is used because the color-blind person escapes de- 
tection with more difficulty, and the diagnosis therefore is all the more 
certainly made, the greater the variety of colors. The normal-eyed in- 
dividual readily selects the right ones from the mass ; whilst the color- 
blind person, although the right ones are directly before him, picks out 
wrong ones, thereby disclosing the character of his defect. 

The test-color with which the examination invariably begins is a pale 
pure green, because green is the whitest of the spectral colors, and, conse- 
quently, the one in which the presence of color is most difficult to recognize 
— the one, in short, most easily mistaken for gray (=no color). We all 
experience the most difficulty in deciding whether there be any color 
at all present in the very deepest shades (nearly black), and in the very 
palest shades (nearly white) ; therefore it was plainly either a very dark 
or a very pale shade of green that should be employed, and Holmgren's 
experience made him decide for the pale shade, as providing the most 
delicate test. 

As a test for the diagnosis of the particular kind of color-blindness, 
Holmgren recommends a purple (deep pink) sample — that is, the whole 
group of colors in which red (orange) and blue (violet) are combined 
in nearly equal proportions, or at least in such proportions that no one 
of them sufficiently preponderates over the others, to the normal color- 
sense, so as to give its name to the combination. Purple is of especial 
importance in the examination of the color-blind, for the reason that 
it forms a combination of two fundamental colors (red and blue) — 
the two extreme colors — which are never confounded with each other. 

The Method of Examination and of Diagnosis is as follows: The 
worsteds are placed in a pile on a table in broad daylight. The test 
skein (pale pure green) is taken from the pile, and laid at a short dis- 
tance from it, so as not to be confounded with the other skeins during 
the trial; and the person examined is then requested to select other 

559 



56o APPENDIX I. 

skeins most resembling this in color, and to place them by the side of 
the sample. It is necessary he should have clearly understood what is 
required of him— namely, that he should search the pile for the skeins 
making an impression on his chromatic sense similar to that made by 
the sample, and independently of any name he may give the color. In- 
deed, it is not desirable that he should be asked to name the colors, and 
he should be discouraged from doing so. The examiner should explain 
that resemblance in every respect is not necessary; that no two speci- 
mens are just alike; that the only question is the resemblance of color; 
and that, consequently, he must endeavor to find something lighter and 
darker of the same color. If the person examined cannot understand 
this verbal explanation, the examiner must resort to action. He must 
himself make the trial by searching with his two hands for the skeins, 
thereby showing what is meant by a shade, and afterwards restoring the 
whole to the pile, except the sample-skein. Or, when a large number 
of persons have to be examined together, it will be more rapid to begin at 
once with such a demonstration before the assemblage. There is no loss 
of security in this, for no one with defective chromatic sense finds 
the correct skeins in the pile any the more easily from the fact of having 
a moment before seen someone else looking for and arranging them. 

On the card which is attached to the inside of the back cover of this 
book there are two classes of wool-samples, (i) The Test-Samples, 
which are placed horizontally. (2) The Colors of Confusion — that is, 
those which the color-blind person selects from the heap of wools, 
because he confuses them with the color of the sample — and these 
are arranged vertically under their respective test-samples. The object 
of this card is merely to illustrate this text. It cannot itself be used 
for testing the color-sense, nor does it contain all the colors and shades 
necessary for the purpose. 

The test is conducted as follows : Test I. The green sample is 
presented. This sample, as already explained, should be of the palest 
shade of very pure green, which is neither yellow-green nor blue-green 
to the normal eye, but fairly intermediate between the two. The ex- 
amination must be continued until the person examined has selected 
all the other skeins of the same color, or else, with these or separately, 
one or several skeins of the class corresponding to the " colors of 
confusion" (i to 5), until he has sufficiently proved, by his manner of 
doing it, that he can easily and unerringly distinguish the confusion 
colors, or until he has given proof of unmistakable difficulty in accom- 
plishing his task. He who places beside the sample one of the colors 
of confusion (i to 5) — that is to say, finds that it resembles the test- 
sample — is color-blind. He who, without being quite guilty of this con- 
fusion, evinces a manifest disposition to do so, has a feeble chromatic 
sense. 

If we want to know the kind and degree of the color-blindness 
which the failure to perform Test I. shows to be present, we must pro- 
ceed to 

Test Ila. — A purple skein is shown to the person being examined. 
The trial must be continued until he has selected all, or the greater 



APPENDIX I. 561 

part of, the skeins of the same color, or else, simultaneously or sep- 
arately, one or several skeins of "confusion" (6 to 9). He who con- 
fuses selects either the light or deep shades of blue and violet, especially 
the deep shades (6 and 7), or the light or deep shades of one kind of green 
or gray, inclining to blue (8 and 9). (i) He who is color-blind by Test L, 
and who, upon Test Ila, selects only purple skeins, is termed " incom- 
pletely color-blind." (2) He who, in Test Ila, selects with purple only 
blue and violet, or one of them, is " completely red-blind." (3) He who, 
in Test Ila, selects with purple only green and gray, or one of them, is 
" completely green-blind." The red-blind never selects the colors taken 
by the green-blind, or vice versa. Often the green-blind places a violet or 
blue skein beside the green, but only the brightest shades of these colors. 
This does not influence the diagnosis. 

The examination may end here, and the diagnosis be regarded as 
settled. But to convince railway employers, and shipowners, and their 
employees, a still further trial may be made. It only serves to corroborate 
the diagnosis. 

Test lib. — The red skein is presented. It is necessary to have a vivid 
red color, like the red flag used as signals on railways. This test, which 
is applied only to those either " completely red-blind " or " completely 
green-blind," should be continued until the person examined has placed 
beside the specimen all the skeins belonging to this shade, or the greater 
part of them, or else, separately, one or several " colors of confusion " 
(10 to 13). Alongside the red the red-blind person places green and 
brown shades, which (10 and 11) to the normal sense seem darker 
than red. On the other hand, the green-blind person selects opposite shades 
— those which appear lighter than red (12 and 13). Every case of com- 
plete color-blindness discovered does not always make the precise mis- 
takes just mentioned with Test lib. These exceptions are either persons 
with comparatively inferior degrees of complete color-blindness, or of 
color-blind persons who have been exercised in the colors of signals, and 
who try not to be discovered. They usually, but not always, confound at 
least green and brown. Total color-blindness is extremely rare, but such a 
case would be recognized by a confusion of every color having the same 
intensity of light. 

Violet-blindness will be recognized by a genuine confusion of purple, 
red, and orange in Test lib. 

If further information on the subject be desired, the reader should 
consult Professor Holmgren's original monograph, " De la Cecite des 
Couleurs," Stockholm, 1877, or Dr. Joy Jeffries' " Color-Blindness," 
Boston, 1879. 



47 



APPENDIX II. 



REGULATIONS AS TO DEFECTS OF VISION WHICH DIS- 
QUALIFY CANDIDATES FOR ADMISSION INTO THE CIVIL. 
NAVAL, AND MILITARY GOVERNMENT SERVICES, THE 
ROYAL IRISH CONSTABULARY, AND THE MERCANTILE 
MARINE. 

By an Army Circular issued by the War Office — 

Candidates for Commissions in the Army are required to possess the 
following visual powers. These regulations apply to all branches of 
the service, including the Medical Department. 

Snellen's Test Types are used for determining the acuteness of vision. 

1. If a candidate can read D = 6 at 6 meters (20 English feet), and 
D = 0.6, at any distance selected by himself, with each eye, without 
glasses, he will be considered fit. 

2. If a candidate can only read D = 24 at 6 meters (20 English feet) 
with each eye without glasses, his visual deficiency being due to faulty 
refraction, which can be corrected by glasses which will enable him 
to read D = 6 at 6 meters with one eye, and D = 12 at the same distance 
with the other eye, and can also read D = 0.8 with each eye without 
glasses, at any distance selected by himself, he will be considered fit. 

3. If a candidate cannot read D = 24 at 6 meters (20 English feet) 
with each eye without glasses, notwithstanding that he can read D = 0.6 
he will be considered unfit. 

Squint, inability to distinguish the principal colors, or any morbid con- 
ditions, subject to the risk of aggravation or recurrence in either eye, will 
cause the rejection of a candidate. 

The Royal Navy.— A candidate is disqualified unless both eyes are 
emmetropic. The candidate's acuteness of vision and range of accommoda- 
tion must be perfect. 

2. A candidate is disqualified by any imperfection of his color-sense. 
The author has it on good authority that no absolute rule as to visior 

is laid down with regard to candidates for entry into the Navy Medical 
Service. Each case is determined at the physical examination at the Naval 
Medical Department, which takes place shortly before the competition. 

Full normal vision is not necessarily essential in all cases for Naval 
Medical officers. 

3. Strabismus, or any defective action of the exterior muscles of the 
eyeball, disqualifies a candidate for the Royal Navy. 

The Home Civil Service.— Blindness or defective vision, except a 
moderate degree of ordinary shortsight, disqualifies. But candidates for the 
Customs Outdoor Service must not be shortsighted. 

562 



APPENDIX IL 563 

The Indian Civil Service {Covenanted and Uncovenanted). — i. A candi- 
date may be admitted into the Civil Service of the Government of India 
if ametropic in one or both eyes, provided that, with correcting lenses, 
the acuteness of vision be not less than 6-9 in one eye and 6-6 in the 
other, there being no morbid changes in the fundus of either eye. 

2. Cases of myopia, however, with a posterior staphyloma, may be 
admitted into the service, provided the ametropia in either eye do not 
exceed 2.5 D, and no active morbid changes of chorioid or retina be 
present. 

3. A candidate who has a defect of vision arising from nebula of the 
cornea is disqualified if the sight of either eye be less than 6-12; and in 
such a case the acuteness of vision in the better eye must equal 6-6, with 
or without glasses. 

4. Paralysis of one or more of the exterior muscles of the eyeball dis- 
qualifies a candidate for the Indian Civil Service. In the case of a can- 
didate said to have been cured of strabismus by operation, but without 
restoration of binocular vision, if with correcting glasses the vision reach 
the above standard (i), and if the movement of each eye be good, the 
candidate may be passed. The same rule applies to the case of unequal 
ametropia without binocular vision, both eyes having full acuteness of 
vision with glasses, and good movement. 

The Indian Marine Service {Including Engineers and Firemen). — i. A 
candidate is disqualified if he have an error of refraction in one or both 
eyes which is not neutralized by a concave, or by a convex i D lens, or some 
lower power. 

2. A candidate is disqualified if he cannot distinguish the pri- 
mary colors and their various shades — red, green, violet or blue, and 
yellow. 

3. Strabismus, or any defective action of the exterior muscles of the 
eyeball, disqualifies a candidate for the Marine Service. 

Royal Irish Constabulary— Candidates for cadetships in the Royal 
Irish Constabulary and recruits must be able to read with each eye 
separately, and without glasses, Snellen's metrical test types numbered 
D = 10, at 20 English feet, and those numbered D = 0.8 at any distance 
selected by the candidate himself. 

Squint, inability to distmguish the principal colors, or any morbid 
condition, liable to the risk of aggravation or recurrence in either eye, 
will involve the rejection of the candidate. 

The British Mercantile Marine —An Appendix (Exn. i. Appendix T) 
to the regulations relating to the Examinations of Masters and Mates 
in the Mercantile Marine has been issued by the Board of Trade, and 
came into force on September i, 1894. 

It is entitled " Form Vision, Color Vision, and Color Ignorance 
Tests," and enacts the following rules : 

I. Examinations for Form Vision, Color Vision, and Color Ignorance 
are open to all persons serving or intending to serve in the Mercantile 
Marine, and all such persons are recommended to take the earliest op- 
portunity of ascertaining by means of these examinations whether their 
vision is such as to qualify them for service in that profession, 



564 APPENDIX II. 

2. The examination consists of three parts : 

(a) Form Vision Test; (b) Color Vision Test; (c) Color Ignorance 
Test. 

No candidate will be examined in the Color Vision Test until he has 
passed the Form Vision Test, or in the Color Ignorance Test until he has 
passed the Color Vision Test. 

3. Any person serving or intending to serve in the Mercantile Marine, 
if desirous of undergoing the Form Vision, Color Vision, and Color Ig- 
norance Test only, must make application to the Superintendent of a 
Mercantile Marine Office on the Form Exn. 2a, and must pay a fee of one 
shilling. 

4. Every candidate for a Certificate of Competency who is not already 
in possession of such a Certificate will be required to pass the three tests 
mentioned in Rule 2 before he can proceed to the examination in Nav- 
igation and Seamanship for the Certificate which he desires to obtain, 
even though he may have passed the tests on some previous occasion. 

5. Every candidate who is already in possession of a Certificate of 
Competency, and who desires to obtain a Certificate of a higher grade, 
will be required to pass the three tests mentioned in Rule 2 before he 
can proceed to the examination in Navigation and Seamanship for the 
Certificate of a higher grade. 

That is to say, no candidate will be permitted to proceed with the 
examination in Navigation and Seamanship for a higher Certificate if he 
fail to pass the three tests. 

6. If a candidate fail to pass any of the three tests, a note of the fact 
of his having done so will be written across the face of the Certificate 
which he already possesses before the Certificate is returned to him. 

7. If a candidate who undergoes the Form Vision, Color Vision, and 
Color Ignorance Tests only (see Rule 3) be in possession of a Certificate 
of Competency, he must hand in his Certificate before the examination 
commences, and if he fail to pass any of the three tests, a statement of his 
failure will be written on the Certificate before it is returned to him. 

8. Candidates who fail to pass the Form Vision Test or Color Igno- 
rance Test can be re-examined at intervals of three months, but candidates 
who fail to pass the Color Vision Test cannot be re-examined. It is open, 
however, to any candidate who has failed to pass that test to appeal to 
the Board of Trade, who may, if they think fit, remit the case to a special 
examiner or body of examiners for final decision. 

9. The expenses of candidates who are examined by the special ex- 
aminers, and are reported by them to have passed the three tests, will, 
under certain circumstances, be paid by the Board of Trade, at a rate 
which will be notified to the candidate, but no payment whatever will 
be made towards the expenses of candidates who upon their own applica- 
tion are examined by the special examiners and are reported by them to 
have failed. The special examinations will be held in London only. 

10. When a candidate fails to pass the Color Test the Examiner will 
point out to him the conditions under which he can appeal. Appeals are 
to be made through the Examiner, and forwarded to the Board of Trade 
with the Examiner's remarks. 



APPENDIX 11. 565 

11. The holder of a Certificate which bears on it a statement of failure 
in the first test (Form Vision) or in the third test (Color Ignorance) can 
have the statement removed by passing after the prescribed interval the test 
to which it refers, but the instruction in the last paragraph of Rule 2 must 
be followed. 

12. The fee paid for examination for a Certificate of Competency in- 
cludes the fee of One Shilling for examination in Form Vision, Color 
Vision, and Color Ignorance, and if the candidate fails to pass those tests, 
will, with the exception of One Shilling, be returned to him. 

13. Only Examiners who have themselves passed the Color Test are to 
undertake these examinations. 

Form Vision Test. — The tests to be used are Snellen's Letter Test for 
candidates who can read, and the dot tests for those who cannot read. 
The sets of tests which have been supplied to the examiners consist re- 
spectively of eight sheets of Snellen's letters and two sheets of dots. 

Candidates may use both eyes or either eye when being tested, but 
they must not be allowed to use spectacles or glasses of any kind. If 
the candidate can read correctly, at a distance of sixteen feet, three 
of the five letters in the fifth line from the top, or four of the letters 
in either of the two lines below, he may be considered to have passed 
the test. If he cannot do so, he should be treated as having failed. 

If the candidate cannot read he must be tested with the sheet of 
dots. For this test he is to be placed at a distance of precisely eight 
feet from the test sheets, and exactly opposite them. One of the sheets 
of dots is then to be exposed, and the candidate should be asked to 
name the number of dots in one or two of the lines or groups. Lines 
and groups of dots can be formed by holding a piece of white paper 
over part of the sheet, but care must be taken that when this is being 
done the candidate's view is not obstructed or the light on the test sheet 
in any way obscured. 

If the candidate answer the questions put to him by the examiner 
with complete or very nearly complete accuracy, he should be treated 
as having passed. If he does not answer with very nearly complete 
accuracy, he should be treated as having failed. 

Color Vision Test. — The Color Vision of candidates is to be tested 
by means of Holmgren's wools. 

Color Ignorance Test. — The object of this test is simply to ascertain 
whether the candidate knows the names of the three colors — red, green, 
and white — which it is important for every seaman to be acquainted with, 
and the test is to be confined to naming those colors. 

One or two of the purest red and green skeins should be selected from 
the set of wools, and the candidate should be required to name their 
colors. He should also be required to name the color of any white object, 
such as a piece of white paper. 

If he answer correctly, he should be considered to have passed the 
test. If he make any mistake, he should be tried with the lantern which 
was formerly used for color tests, the plain glass and the standard red and 
green glasses being employed for the purpose. If he does not name these 
glasses correctly, he should be reported as having failed to pass the test. 



vertical +iqo 




Snellen's Sunuise Figure for Testing for Astigmatism {See p. 55.) 



INDEX. 



Abscission for corneal staphyloma, 
170. 

Abscess, cerebral, 425; corneal, 140, 
161 ; of eyelid, 187. 

Accommodation, 18, 19, 60; ampli- 
tude of, 21, 63, 65, in myopia, 44. in 
hypermetropia, 39 ; anomalies of^ 
64; cramp of, 48; definition of, 19; 
mechanism of, 19; muscle of, 49; 
paralysis of, 40 ; pupillary contrac- 
tion in, 20; relative, 22; relaxation 
of, 73; spasm of, 40, 41. 42, 69; 
Tscherning's theory of, 20. 

Accommodative asthenopia, 40, 41, 69, 

93. 
Acromegaly, 529. 
Actinomyces, 234. 
Acuteness of vision. 28, 32. 
Adenoma of the eyelids, 197. 
Agraphia, 534. 
Albinismus, 91, 298, 499. 
Albuminuria of pregnancy, 403, 405. 
Albuminuric retinitis (see Retinitis). 
Alexia, 533; cortical, 534; subcortical, 

534. 

Amaurosis. 136, 432, 434, 438; from 
blepharospasm, 136, 503 ; quinin, 
413; reflex, 503; spinal, 434, 435; 
supra-orbital. 545. 

Amaurosis, pretended, 556. 

Amaurotic family idiocy, 538. 

Amblyopia. 63, 413, 415, 422, 429, 433, 
438, 477; alcoholic, 311; central, 
408, 439 ; congenital, 553 ; ex anop- 
sia, 476 ; from direct sunlight, 414 ; 
from hemorrhages, 437 ; f roni 
wounds of the supra-orbital nerve. 
554; glycosuric, 439; in hysteria. 
551; in neurasthenia, 549; in trau- 
matic neurosis, 551; nervous. 547; 
of the squinting eye, 476; reflex, 
553; tobacco or toxic central, 310, 
429, 439; transitory, 542; uremic, 
555 ; various forms of, 552 ; with 
eccentric fixation, 477. 

Ametropia, 36, 474, 477. 



Amnesia, optic, 535. 

Amnesic color-blindness, 535. 

Amyloid degeneration of the conjunc- 
tiva, 120. 

Anemia, 519; progressive pernicious, 
410. 

Anesthesia of the conjunctiva and 
cornea. 529. 

Anesthetics, local, in ophthalmology, 
319- 

Aneurysm, 403; arterio-venous, 509; 
of carotid, innominate, or aorta, 311, 
411; of the internal carotid, 509; 
of the ophthalmic artery, 509; per 
anastomosis, 509 ; traumatic, 509. 

Angle alpha, 24 ; gamma, 24, in hyper- 
metropia, 39, in myopia, 45 ; of con- 
vergence, 24; the meter, 24; the 
visual, 29. 

Aniridia (or Irideremia), congenital, 
297; traumatic. 287. 

Anisometropia, 64. 

Ankyloblepharon, 229. 

Anosmia, 529. 

Anterior chamber, hemorrhage into, 
368 ; late appearance of, after cata- 
ract extraction, 370. 

Anterior corpus quadrigeminum, 
lesions of the, 531. 

Antrum, maxillary, tumor in the, 511 ; 
of Highmore. tumor in the, 51 ij 
sphenoid, tumor in the, 511. 

Aphakia, 369, 381, 382. 

Aphasia, 553 ; motor, 530 ; visual, 534. 

Apoplexy, cerebral, 471, 519. 

Arcus senilis. 185. 

Arecoline, hydrobromate, 318. 

Argyll Robertson's operation for ec- 
tropion, 225; pupil, 538, 544. 

Argyrosis, 96. 

Arlt-Jaesche operation for trichiasis, 

214. 

Arlt's operation for cicatricial ec- 
tropion, 228. 

Army, vision required for commis- 
sions in the, 562. 



567 



568 



INDEX. 



Asthenopia, accommodative. 40, 41; 
conjunctival, 93; muscular, 494'; 
nervous, 547; retinal, 477. 

Asthma, 106. 

Astigmatism, 36, 50, 51, 52, 85, 383; 
after cataract operations, 383 ; cor- 
neal, 64; determination of, by 
ophthalmoscope, 79, by retinoscopy, 
60; estimation of degree of, 57, by 
astigmometer, 60; headache due to, 
56; hypermetropic, compound, 54, 
59, simple, 54, 58, 192; irregular, 
64, 174; lental, 63, dynamic or ac- 
tive, 63, static or passive, 63 ; mixed, 
54, 60, 85 ; myopic compound, 54, 
59; simple, 54, 58; regular, 52, 54; 
spectacles in, 57 ; symptoms of, 55. 

Astigmometer, the, 58, 61. 

Ataxic paraplegia, 499, footnote. 

Ataxy, hereditary, 545 ; locomotor, 
434, 462, 463 ; of the orbital muscles, 

543- 

Atheroma, 403, 411, 412. 

Athetosis, 531. 

Atrophy of the optic nerve (see Optic 
nerve). 

Atropin, 40, 60, 63, 68, 69, 73, 84, 102, 
117, 138, 144, 14a 150, 152, 155, 158^, 
162, 165, 166, 168, 176, 180, 182, 187; 
251, 256, 268, 277, 284, 286, 287, 289, 
309, 316, 335, 338, 342, 347, 354, 369.. 
372, 375, 377, 378, 396, 485, 554 ; dan- 
ger of glaucoma from use of, 257; 
poisoning by, 257 

Axis, optic, 24. 

Bader's operation for conical cornea, 

175. 
Base of skull, fracture of, 127. 
Basedow's disease, 517. 
Bergeon's treatment of rodent ulcer 

of the eyelid, 191. 
Berlin's operation for entropion, 220. 
Binocular vision, 64. 
Birnbacher's operation for ptosis, 201. 
Bisulphid of carbon, poisoning by, 

431. 
Black spot m myopia, 47. 
Blennorrhea, acute, of conjunctiva, 

97, 126, 141 ; chronic of conjunctiva^ 

98 ; neonatorum, 97 ; of the lacrimal 

sac, 237. 
Blepharitis. 94, 356; chronic, 211; in- 

termarginal, 94; marginal, 191; 

squamosa, 191; ulcerosa, 191. 



Blepharophimosis, 210. 

Blepharoptosis, 198. 

Blepharospasm, 134, 135, 141, 197. 

Blind spot, the, 34, 46. 

Blows on the eye, 180. 

Bowman's operation for conical 
cornea, 175. 

Brain, basic lesions of the, 447 ; diag- 
nosis of, 468; focal disease of the. 
522, pontine lesions of the, 447. 

Bright's Disease, 355, 403, 405, 411, 
413,^428. 

Broca's lobe, lesion of, 535. 

Bronchitis, 106, 264. 

Bulbar paralysis, 69. 

Bulla of the cornea, 123, 180. 

Buphthalmos, 340. 

Canaliculus, obstruction of the, 234. 

Canthoplastic operation, 211. 

Capsule, lesion of the internal, 530. 

Capsulotomy, 379; Bowman's method 
of, 380; Knapp's method of, 381; 
Noyes' method of, 380. 

Carcinoma, 508; of chorioid, 294; of 
ciliary body, 292 ; of orbit, 508. 

Caries of nasal bones, 241 ; of the 
orbit, 503; of the teeth, 553. 

Caruncle, sinking of the, 490, 493. 

Cataract, 42, 419; membranous, 344; 
black, 345, .349; accreta, 352; arti- 
ficial ripening of, 348; calcareous, 
352 ; capsular, 353 ; central capsular. 
104, 353 ; central lental, 350 ; com- 
plete, 342; complete congenital, 349; 
complete, of young people, 349; 
congenital, 262 ; diabetic, 349 ; 
discission, or dilaceration of, 
376 ; fusiform, or spindle-shaped, 
351 ; glaucoma after extraction 
of, 375 ; linear extraction for, 
357; mental derangement after 
extraction of, 375 ; modified peri- 
pheral linear extraction of, 360; 
Morgagnian, 344; myopia in incipi- 
ent, 45 ; combined, or three-milli- 
meter flap, operation for, 362; or 
extraction of, with iridectomy, 
362; operation for simple, without 
iridectomy, 373; pathogenesis of. 
342; polar, anterior, or pyramidal. 
104, 351 ; posterior, 352 ; ripeness of. 
343; secondary, and its operation. 
379; total, 352; senile. 342; specta- 
cles after extraction of, 382, in in- 



INDEX. 



569 



cipient, 347; spontaneous cure of, 
344; suction operation for, 378; 
symptoms of, 346; traumatic, 353; 
von Graefe's operation for, 360; 
zonular, or lamellar, 350. 

Cautery, use of the actual, 145, 151, 
153, 155, 176. . 

Cavernous sinus, thrombosis of the, 
312, 469, 501. 

Cellulitis, 412, 501, 505. 

Cerebellum, tumor of the, 470. 

Cerebral abscess, 425 ; cysts, 425 ; em- 
bolism, 310; hemorrhage, 530; 
hemispheres, tumors of the, 469^ 
localization, 470; peduncle, lesions 
in the, 470. 

Cerebral tumors, 310, 312, 429; 
ophthalmoscopic appearances in, 
424 ; the pupil in, 310. 

Cerebritis, 426. 

Chalazion, 194. 

Chemosis, 93, 98, 173, 469. 

Chiasma, lesion of the, 522, 528. 

Chlorosis, 427, 519. 

Choked disc, 424. 

Cholera, Asiatic, 504. 

Cholesterin in the vitreous humor, 
387. 

Chorea, 411, 542. 

Chorioid, central senile areolar 
atrophy of the, 296 ; coloboma of 
the, 499 ; detachment of the, 295j 
27S ', extravasation of the blood in 
the, 288; foreign bodies in the, 288 j 
inflammation of the, 261 ; injuries ot 
the, 288 ; miliary tubercles in the, 
540; rupture of the, 288; sarcoma 
of the, 292; staphyloma of the, 
295- 

Chorioidal atrophy, general, 47, 409; 
carcinoma, 294 ; degeneration, near 
macula lutea, 46 ; exudation, near 
macula lutea, 47; ring, 88; osteo- 
sarcoma, 294 ; sarcoma carcinomato- 
sum, 294 ; tubercle, 294. 

Chorioiditis, 189, 289 ; central, 263, 
senile guttate, 262, 356 ; dissemin- 
ated or exudative, 261, 352, 355, 401 ; 
embolic, 264; posterior sclero-, 295"; 
purulent, 263, 328; syphilitic, 262. 

Chorioido-retinitis, chronic, 295. 

Chromidrosis, palpebral, 195. 

Cicatrix, cystoid. 285, 333, 372. 

Ciliary body, carcinoma of the,_ 292; 
inflammation of the, 259; injuries 



of the, 287; myosarcoma of the, 

292; sarcoma of the, 292. 
Ciliary muscle, 19, 66; cramp of the, 

38, 39, 40. 
Ciliary neuralgia, 112, 293, 329. 
Circle of diffusion, 19. 
Circumlental space, 330. 
Civil Service, vision lequired for the, 

562. 
Climacteric period, 410. 
Cocain, 309, 319. 
Coloboma of the chorioid, 298, 499; 

of the eyelid, 232; of the iris, 

297- 
Color-blindness, 26, 27, 28, 435, 439, 

535; amnestic, 535- 
Color-sense, 25 ; theories of the, 25, 

26, 27. 
Commotio retinae, 422. 
Concave lens, 170. 
Concussion, injury to optic nerve by^ 

503. 

Condyloma of the iris, 254. 

Congestion papilla, 424. 

Conical cornea, 173. 

Conjugate deviation of eyes, 469. 

Conjunctiva, amyloid degeneration of 
the, 121 ; anesthesia of the, 529; 
burn of the, 132; cyst of the, 129; 
cysticercus under the, 130; dermoid 
of the, 128; diseases of the, 95; 
ecchymosis under the, 127 ; epitheli- 
oma of the, 129; essential shrinking 
of the, 124; hemorrhage in the, 120; 
hyaline degeneration of the, 120; 
hyperemia of the, 93; injuries of 
the, 131; lipoma of the, 128; lithi- 
asis of the. 130; lupus of the, 122; 
lymphoma of the, 117; nevus of the, 
127; papilloma of the, 128; pem- 
phigus of the, 122; Pinguecula of 
the, 127; polypus of the, 127; sar- 
coma of the, 129 ; syphilitic disease 
of the, 128 ; tubercle of the, 121 ; 
xerosis of the, 123. 

Conjunctival complication of small- 
pox, 119. 

Conjunctivitis. 93-356. 503, 540, 554; 
catarrhal or simple acute, 94 ; 
croupous, 117, 123; diphtheritic, 
116, 118, 123, 141; follicular, 104, 
257; gonorrheal, 97; granular, 107; 
petrificans, 130; phlyctenular, 133; 
purulent, iii, 150; spring catarrh. 
105. 



570 



INDEX. 



Constabulary, Royal Irish, vision re- 
quired for the, 563. 

Contact glasses, 175. 

Contraction, consensual, of pupil, 304. 

Convergence, angle of, 24; and ac- 
commodation, connection between, 
22. 

Convex lenses, 17, 52. 

Convulsions, 478. 

Corectopia, 297. 

Cornea, 17; abrasions of the, 179; 
abscess of the, 141, 161 ; abcission of 
the, 170; absorption ulcer of the, 
155 ; anesthesia of the, 326, 518, 529; 
arcus senilis of the, 185; bullae of 
the, 180; burns of the, 181 ; calcare- 
ous film of the, 168; cautery in 
treatment of ulcers of the, 154; 
conical, 42. 173; cysts of the, 177; 
dermoid of the, 177 ; diseases of the, 
140, disjunction of the, 179; ec- 
tasies of the, 169; epithelioma of 
the, 177; faceted ulcer of the, 156; 
fibroma of the, 177; foreign bodies 
in the, 177; globosa, 340; herpes of 
the, 156; infantile ulceration of the, 
with xerosis of the conjunctiva, 
15; inflammations of the, 140; 
injuries of the, 177; leukoma 
of the, 183; macula of the, 183 j 
nebula of the, 183 ; opacities of the. 
477; paracentesis of the, 147, 150; 
perforating injuries of the, 181, 339; 
perforation of the, 144; phlyctenu- 
lar disease of the, 133; recurrent 
abrasion of the, 179; ring ulcer of 
the, 154; sclerotizing opacity of the, 
168, 246; staphyloma of the, 169; 
tattooing of the, 184 ; transplanta- 
tion of the, 184; transverse calcare- 
ous film of the, 168 ; tumors of the, 
177; ulcer, absorption of the, 155; 
ulcer, deep, of the, 150; ulcer, fac- 
eted, of the, 15s; ulcer, rodent, of 
the, 153; serpiginous ulcer of the, 
151; simple ulcer of the, 149; su- 
perficial transparent ulcer of the, 
155 ; ulceration of the, 143, 145, 418, 
540. 
Corneal deposits, punctate, 253, 271, 

272, 273. 
Corona radiata. lesions of the, 447. 
Corpora quadrigemina, lesions of the. 

Cramp, clonic, of orbicularis, 197; 



tonic, of orbicularis, 197; of ciliary 

muscle, 39. 
Crus cerebri, lesion of the, 467, 468. 
Crystalline lens, 17, 20, 51, 64, 148; 

absence of the, 382; disease of the, 

342; dislocation of the, 381. 
Cyclitis, 188, 259, 288, 362, 417, 419; 

plastic, 260; primary idiopathic, 

260; purulent, 261. 
Cylindrical lenses, 57. 
Cyst, cerebral, 425, 529; of cornea. 

177; of eyelid, 232; of iris, 289; 

orbital, 507; simple, of conjunctiva, 

129. 
Cysticercus, subconjunctival, 130; 

subretinal, 417. 

Dacryoadenitis, 242. 

Dacryocystitis, 153, 356; acute, 117, 
241; chronic, 152, 237; phlegmon- 
ous, 241. 

Dacryolith, 234. 

Daturin, 309. 

Davidson's, Mackenzie, method for 
employing Rontgen rays, 390. 

Decentration of spectacle glasses, 67j 
497- 

Delirium tremens, 431. 

Dermoid tumors of the conjunctiva 
and cornea, 128, 262; of the orbit, 
507. 

Diabetes, 69, 256, 270, 274, 355, 431, 
439, 461. 

Dianoux' operation for trichiasis, 215. 

Dinitro-benzol, poisoning by, 431. 

Dioptric unit, 17, media, 17, system, 
18. 

Dioptry, the, 17. 

Diphtheria, 68, 119, 461. 

Diphtheritic conjunctivitis, 118. 

Diplopia, 126, 446, 452. 463, 487, 506; 
crossed, 449, 452, 454, 456, 476, 555 ; 
homonymous, 449, 450, 452, 456, 
475 ; in concomitant convergent 
strabismus, 476; in insufificiency of 
the internal recti, 494; monocular, 
286; test, 556. 

Direct ophthalmoscopic method. 72. 

Disc, optic (see Optic papilla). 

Discission or dilaceration of lens, 376. 

Disseminated sclerosis (see Sclero- 
sis). 

Distichiasis, ill, 211. 

Duboisin, 309. 

Dyslexia, 534. 



INDEX. 



571 



Eccentric vision, 30. 

Ecchymosis of the conjunctiva, I27._ 

Eclipses, blinding of the retina in, 

414. 
Ectropium, 223; cicatricial, 223, 228; 

muscular or spastic, 223 ; of the lid, 

223, 503; senile, 224; operation for, 

224. 
Eczema, 136, 138, 187. 
Edema of eyelids, 97, 197; of orbital 

tissues, 505. 
Electric light, effect of, on the eyes, 

415- 

Electrolysis, 127, 212, 237, 422; for 
nevi of the eyelids, 195 ; for trichi- 
asis, 212; in detachment of retina, 
422. 

Electro-magnets, 394. 

Elephantiasis lymphangioides of lids, 

197. 
Embolism, cerebral, 527, 542 ; of 

retinal vessels, 400, 410, 411. 
Emmetropia, 18. 
Encephalocele, 507, 512. 
Encephalopathia saturnia, 541. 
Endarteritis, of retinal vessels, 413. 
Endocarditis, 104, 264, 411. 
Enophthalmos, 504, 
Entropion, iii, 123, 211, 218; senile, 

218, 221 ; spastic, 218. 
Enucleation, 122, 171, 278, 513. 
Ephedrin, 317. 
Epicanthus, 231. 
Epilepsy, 56, 127, 310, 312, 433, 494, 

541- 
Epiphora, 233, 238, 545. 
Episcleritis, 244, 245. 
Epithelioma of the conjunctiva, 129; 

of the cornea, 177; of the eyelid, 

197. 
Erysipelas of the eyelids, etc., 187, 197, 

241, 412, 426, 469, 501, 503. 
Erythema. 187. 
Erythropsia, 383, 557. 
Eserin (or Physostigmin), 137, 309, 

318, 337, 3^2. 
Ethmoid cells, enchondromata in, 511 ; 

fibromata in, 511; tumors of, 510, 

511- 
Eucain B, 319. 
Euphthalmin, 317. 
Everbusch's operation for congenital 

ptosis, 204. 
Evisceration of the eyeball, 171, 275, 

278. 



Excision of the eyeball (see Enucle- 
ation). 

Exophthalmic goiter, 515, 517; Dal- 
rymple's sign in, 518; Stellwag's 
sign in, 518; von Graefe's sign in, 
517. 

Exophthalmos, 245, 469, 501, 502, 503, 
504, 507, 512; caused by bleeding 
into the capsule of Tenon, 493; 
monolateral. 505 ; pulsating, 509. 

Exostosis of the orbit, 508, 510, 529; 
in the sphenoid antrum, 511. 

External geniculate body, lesion of 
the, 531 ; recti, insufficiency of the, 
474, 489; rectus, advancement of 
the, 481, 488, 491. 

Eyeballs, motions of, and their de- 
rangement, 441. 

Eyelashes, lice on the, 195. 

Eyelid, adenoma of the, 197 ; chromi- 
drosis of the, 195 ; congenital colo- 
boma of the, 232 ; cramp of the_, 
197; diseases of the, 187; ecchymo- 
sis of jthe, 231 ; ectropion of the, 
223, eczema of the, 187 ; elephanti- 
asis of the, 197 ; emphysema of the, 
231; entropion of the, 218; epithe- 
lioma of the, 197 ; herpes zoster of 
the, 187; injuries of the, 230; in- 
version of the, 218; lupus of the, 
197; milium of the, 194; molluscum 
of the, 195 ; nevi of the, 195 ; restor- 
ation of the, 229; rodent ulcer of 
the, 190; sarcoma of the, 197; stye 
on the, 193; syphilitic sores of the 
189; vaccine vesicles on the, 
190. 

Far point, 18, 20. 

Fascicular paralysis, 463. 

Fatigue field, 548, 550; in traumatic 
neurosis, 552. 

Field of vision, 30; binocular, 34; 
dimensions of, 30; for colors, 34; 
in glaucoma. 324, 325 ; in toxic am- 
blyopia, 429; in optic atrophy, 435; 
in functional neurosis, 547. 

Fifth nerve, influence of the, on the 
pupil, 307; paralysis of the, 471. 

Fixation, field of, 446; line of, 24; 
object of, 30; point of, 24. 

Fluorescin, 142, 147. 

Focal disease of brain, 522 ; illumina- 
tion, 87, 141 ; interval, 53 ; length 
of trial lenses, 17. 



572 



INDEX. 



Focus, conjugate, 19; principal, of the 

eye, 18. 
Foramen, fracture of the margin of 

the optic, 503. 
Foreign bodies in the cornea, 177; in 

the interior of the eye, 388; in the 

iris, 285. 
Form sense, 28. 

Fourth nerve, paralysis of the, 469. 
Friedreich's disease, 545. 
Frontal sinus, osteoma of the, 510; 

tumors of the, 510. 
Fundus oculi, the, 88, 90. 

Gaillard^s sutures, 221. 

Galvano-cautery, 137, 372, 435, 457. 

Gamma, angle, 24. 

Ganglia, primary optic, lesions of the, 
53r._ 

Ganglion, ciliary, 306; Gasserian 
307, 308; hebenulse, 305. 

General paralysis of the insane, 538, 
434. 

Geniculate body, lesion of the exter- 
nal, 305. 

Glaucoma, 257, 289, 320, 403, 410, 548 ; 
absolute, 150, 352; acute, 163, 329; 
etiology of, 329; fulminans, 328; 
hemorrhagic, 340, 410; pathology 
of» 330; primary, 320, 321, 326; 
■ secondary, 255, 285, 290, 320, 339, 
354, 378, 417; treatment of, by 
iridectomy, 332, by myotics, 338, by 
posterior sclerotomy, ^33^ by scler- 
otomy, 336, by sympathectomy, ss7- 

Glaucomatous attack, 327 ; cup, 322 ; 
degeneration, 328; ring, 325. 

Glioma of the retina, 416; pseudo-, 
263, 384, 417- 

Globulin, 353. 

Goiter, exophthalmic, 325, 463, 517. 

Gonorrheal arthritis, 104 ; ophthal- 
mia, 97. 

Gout, 245, 249, 270. 

von Graefe's operation for conical 
cornea, 175, for senile entropion, 
222; sign in exophthalmic goiter, 
517; test for insufficiency of the 
internal recti, 495. 

Granular conjunctivitis (see Tra- 
choma). 

Granuloma of the iris, 194, 289. 

Graves' Disease, 505, 517. 

Green's operation for entropium, 
219. 



Hallucinations, visual, 535, 550; in 
connection with glaucoma, 535. 

Harlan's operation for symblepharon, 
209. 

Hay fever, 106, 

Helmholtz's ophthalmometer, 60 ; 
ophthalmoscope, 71. 

Hematemesis, 410, 438. 

Hemiachromatopsia, 525, 529, 530. 

Hemianesthesia, 468. 

Hemianopic prism phenomenon, 532 ; 
pupil, 532. 

Hemianopsia, 425, 439, 462, 466, 469, 
522; absolute, 523; altitudinal, 523, 
529, 553; bitemporal, 511, 528, 529; 
complete, 523; cortical, 530; 
homonymous, 304, 523, 529 ; in com- 
plete or partial, 523 ; localization of 
the lesion, in cases of, 528 ; nasal, 
523, 529; relative, 523; superior and 
inferior, 523; temporal, 523; transi- 
tory, 552. 

Hemiatrophy, facial, 504. 

Hemiplegia, 462, 468, 469, 470, 471 ; 
crossed, 468. 

Hering's drop experiment, 486, foot- 
note ; theory of the color-sense, 25. 

Hernia cerebri, 512. , 

Herpes corneas febrilis, 156; herpes 
zoster ophthalmicus, 156, 187. 

Heterophthalmos, 297. 

Hippus, 305, 308, 313. 

Holmgren's method for testing the 
color-sense, 559. 

Holocain, 319. 

Homatropin, 317. 

Hemophthalmos, 248. 

Hemorrhage, cerebral, 530; from 
stomach, bowels, or uterus, 437, 
519; in anterior chamber, 181; in 
retina, 51, 121, 400, 633; at yellow 
spot, 48; in vitreous humor, 386, 
398, 

Hooping-cough, 127, 158, 264. 

Hordeolum, 193. 

Hot eye, 244. 

Hotz's operation for senile entro- 
pium, 222, 

Hyaline degeneration of the conjunc- 
tiva, 121. 

Hyaloid artery, persistent, 397. 

Hydrocephalus, 426, 433, 434, 462, 540. 

Hydrophthalmos, congenital, 340. 

Hyoscyamin, 309. 

Hyperemia of the papilla, 88, 



INDEX. 



573 



Hyperesthesia of the retina, 553. 

Hyperbohc lenses, 174. 

Hypermetropia, 36, 52, 192, 475 ; ac- 
commodative asthenopia in, 40; am- 
pHtude of accommodation in, 39; 
angle gamma in, 39; axial, 36; esti- 
mation of, by ophthalmoscope. "]'] ; 
by retinoscopy, 80 ; cause of inter- 
nal strabismus in, 474; convergent 
concomitant strabismus in, 41 ; cor- 
rection of, 2>7 '•> cramp of ciliary 
muscle in, 39; curvature, 36; latent, 
40; manifest, 38, 40; spectacles in, 
41 ; the pupil in, 303. 

Hyperostosis of the orbit, 529; in the 
sphenoid antrum, 511. 

Hvphema, 248, 284. 

Hypopyon, 135, 138, 143, 145, 259, 393. 

Hysteria, 519, 547- 

Idiocy, amaurotic family, 538. 

Illaqueatio, 212. 

Image, inverted ophthalmoscopic, ']2)\ 
upright opthalmoscopic. 72. 

Influenza, 68, 429, 432, 461, 501, 545- 

Insomnia, 550. 

Insufficiency of convergence, 494. 

Intermittent fever, 158. 

Internal capsule, lesion of the. 471^ 
530, 531 ; recti, insuthciency of the^ 
48, 67 ; rectus, tenotomy of the, 481, 
488. 

Intra-ocular media, 18. 

Iodoform poisoning. 431. 

Iridectomy, 300, 376; for glaucoma,, 
332, 338 ; in cataract operations, 
361, in sympathetic ophthalmitis, 
282; instruments for, 300; optical, 

175- 

Irideremia, 297. 

Iridis, rupture of the sphincter, 286. 

Iridochorioiditis, 120, 255, 289; plastic, 

540- 

Iridocyclitis, 120, 151, IS9» 250, 255, 
293, 330, 340, Z72>. 2)79, 398; chronic, 
418. 

Iridodialysis, 285. 

Iridodonesis, 381. 

Iridoplegia, 312. 

Iridotomy, 302, 380. 

Iris, absence of the, 287 ; coloboma of 
the, 297; cysts of the, 289; dehis- 
cence of the, 286 ; foreign bodies in 
the, 285 ; granuloma of the, 289 ; in- 
juries of the, 284; malformations 



of the, 297 ; operations on the, 300 ; 
persistent pupillary membrane of 
the, 297 ; prolapse of the. 134, 137. 
148, 182; retroflexion of the, 286; 
rupture of sphincter of, 286; sar- 
coma of, 291 ; tubercle of the, 
289. 

Iritis, 94, 95, 102, 112, 120, 135, 138, 
144, 151, 189. 372, 378, 405< 417, 
419; gonorrheal, 253; purulent, 
259 ; quiet, 252 ; rheum.atic, 253 ; 
serous, 253; symptoms of, 251; 
syphilitic, 253, 254, 259; tubercular, 
289. _ 

Irritation, sympathetic, 265. 

Jacob's ulcer, 190. 
Japanese muff-warmer, 145, 165. 
Javal's orthoptic treatment for stra- 
bismus, 485. 
Jequirity. 115. 

ICeratitis, 120; aspergillina, 161; 
bullous, 159; dendriform, 160; 
diffuse interstitial, or parenchyma- 
tous, 162, 540; fascicular, 134; fila- 
mentary, 159; grating-like, 166; 
guttate, 167; neuroparalytic, 155; 
phlyctenular, 126, 135, 141 ; pro- 
funda, 165 ; punctata. 167, 253 ; 
purulent, 264 ; riband-like, 168 ; 
striped, 370. 

Keratoconus, 173. 

Klebs-Loffler bacillus. 118, 119. 

Knapp's operation for tumor of optic 
nerve, 437. 

Koch-Weeks' bacillus, 95, 98. 

Kronlein's operation, 515. 

Kuhnt's operation for extirpation of 
lacrimal sac, 239; for ectropion, 
224. 

Lacrimal apparatus, diseases of the. 
233 ; canaliculus, obstruction of the, 
234; duct, stricture of the, 236; 
fistula, 239. 

Lacrimal gland, extirpation of the, 
243; hypertrophy of the, 242; in- 
flammation of the, 242 ; removal of 
the, 241, 243; tumors of the, 512. 

Lacrimal punctum, inversion of the, 
233 ; stenosis and complete occlu- 
sion of the, 233. 

Lacrimal sac, lupus of the, 122 ; blen- 
norrhea of the, or chronic dacry- 



574 



INDEX. 



ocystitis, 237; extirpation of, 239; 

obliteration of, 239. 
Lagophthalmos, 207, 471. 
Lamellar, or zonular, cataract, 350. 
Lamina cribrosa, 89, 323, 437. 
Landry's disease, 546. 
Lateral sclerosis, 434. 
Lead poisoning, 428, 461. 
Left ventricle, hypertrophy of the, 

410. 
Lens, crystalline, discission of, 51^ 

282, 349, 350; dislocation of, 339, 

352; extraction of, 282; injury of, 

340; lateral displacement of, 339 j 

sclerosis of, 52, 255. 
Lenses, concave, 17; convex, 17; 

cylindrical, 57; numbering of trial 

and spectacle, 17. 
Lental astigmatism, 63. 
Lenticular nucleus, lesions of the, 

533. 
Lenticonus, 382. 

Leptothrix in the canaliculus, 234. 
Leukemia, 405, 509. 
Leukoma of the cornea, 144, 183 ; ad- 
herent, 103, 150, 151 ; tattooing for, 

184. 
Lice on the eyelashes, 193. 
Light difference, 25 ; minimum, 25 ; 

sense, 25. 
Lipoma of the conjunctiva, 128. 
Lithiasis of the conjunctiva, 130. 
Locomotor ataxy (see Tabes dor- 

salis). 
Lupus of the conjunctiva, 122; of the 

eyelids, 197 ; of the lacrimal sac, 

122. 
Lymphadenoma of the orbit, 505, 508, 

509. 

Macula Cornea, 144, 183, 449, 452, 

475. 

Macula lutea. 18, 48, 76, 84, 89, 401, 
402, 406, 408, 410, 411, 475; exuda- 
tion at the, 263. 

Macula, Trousseau's cerebral, 519. 

Macular center in cortex, theory of 
arrangement of, 527. 

Madarosis, 190. 

Maddox's rod-test, 496. 

Magnet, the, for removing foreign 
bodies, 394. 

Malaria, 245, 400, 429. 

Malingering, tests for, 555. 

Mania, acute, 311, 312. 



Marasmus, 539, 

Massage of eyeball, 412. 

Maxwell's operation for shrunken 
sockets, 513. 

Measles, 95, 134, 162, 264, 429, 478. 

Media, dioptic, intra-ocular, or re- 
fracting, 18. 

Megalopsia, 262. 

Meibomian cyst, 194; glands, 94, 194. 

Melancholia, 312. 

Meningitis, 104, 279, 425, 433, 457, 
469; acute, 539; acute tubercular, 
540; basal, 529; cerebro-spinal, 264, 
425, 540; purulent, 501; spinal, 312'; 
syphilitic, 533; traumatic, 540; 
tubercular, 425. 

Meningocele, 513. 

Menstruation, suppression or irregu- 
larity of, 410, 426. 

Mental derangement after cataract 
extraction, 375. 

Mercantile marine, vision required 
for, 563. 

Metamorphopsia, 262, 401, 415. 

Meter angle, 24; lens, 17. 

Metria, 407, 501. 

Metrical system for spectacle lenses, 

17. 

Meynert's fibers, 532. 

Microphthalmos, 499. 

Micropsia, 68, 262, 401. 

Migraine, 532, 542. 

van Millingen's operation for tri- 
chiasis, 217. 

Milium, 194. 

Mind-blindness, 531, 534, 535, 538. 

Mitral disease, 411. 

Molluscum, 195. 

Morax, diplobacillus of, 95. 

Morton's operation for conical cor- 
nea, 176. 

Morvan's disease, 546. 

Mouches volantes, 386. 

Mucocele of the lacrimal sac, 238, 510. 

Mules' operation for corneal staphy- 
loma, etc., 172, 278, 339; for ptosis, 
200. 

Muscae volitantes, 386. 

Muscarin, 309. 

Muscles of the orbit and their de- 
rangements, 441 ; cerebral, paraly- 
sis of the, 464; conjugate lateral 
paralysis of the, 464; paralysis of 
the. 447; normal action of the. 441. 

Muscular atrophy, progressive, 462. 



INDEX. 



575 



Myasthenia gravis, 463. 

Mydriasis, (i^, 68, 311, 455; irritation, 
311; paralytic, 311; traumatic, 286, 
287. 

Mydriatics, action of the, 309. 

Mydrin, 317. 

Myelitis, acute, 428, 545; cervical, 
311; pupillary symptoms in, 546. 

Myodesopsia, 386. 

Myopia, 36, 42; amplitude of ac- 
commodation in, 44; angle gamma 
in, 44; apparent, 39; axial, 42; 
cause of, 45 ; complicated with or- 
ganic disease, 46, 419; curvature, 
42; detachment of the retina in^ 
48, 419; determination of degree 
of, 44; functional anomalies of, 
48; management of, 48; operative 
cure of, 51; pernicious, 46; pre- 
scribing of glasses in, 48; pro- 
gressive, 46. 

Myopic astigmatism, 58; crescent, 46. 

Myosarcoma of ciliary body, 292. 

Myosis, paralytic, 310; traumatic. 287. 

Myotics, action of the, 309. 

Myotonia congenita (Thomson's), 
546. 

Myxo-sarcoma of the optic nerve, 
435- 

Nevus of the conjunctiva, 127; of 
the eyelid, 195. 

Nasal catarrh, 136, 235, 237; duct, 
stricture of the, 235. 

Navy, vision required for the, 562. 

Near objects, 18, 19; point, 21, 64, 66. 

Nebula of cornea, 144, 183. 

Neisser, gonococcus of, 97. 

Nephritis, acute, 403, 405 ; chronicj 
403; of pregnancy, 555. 

Nerve fibers, opaque, 89. 

Neurasthenia, 313; nervous ambly- 
opia in, 549. 

Neurectomy, optico-ciliary, 275, 278, 
280, 338. 

Neuritis, optic, 501, 529, 541, with 
persistent dropping from nostril, 
432 ; peripheral, 428, 463, 544 ; retro- 
bulbar, 427, 432. 

Neuro-paralytic keratitis, 155. 

Neuro-retinitis, 401. 

Neurosis, traumatic, 546, 547; the 
fatigue field in, 552. 

Neurotomy, optic-ciliary, 278, 281. 

Night-blindness, 125, 262, 401, 554. 



Noyes' operation for secondary cat- 
aract, 380. 

Nuclear paralysis, 460 ; acute, 461 ; 
chronic, 461. 

Nuclear pupil-contracting center, 
paralysis of, 309. 

Nucleus, lenticular, tumor of, 533. 

Nystagmus, 298, 349, 499, 537- 

Oblique illumination, 87. 
Occipital lobe, lesion of, 530, 534. 
Ocular diseases and symptoms caused 

by focal brain disease, 522. 
O'Farrell's enucleation, 278. 
Ointment, yellow oxid of mercury,, 

137. 

Omphalophlebitis, 264. 

Opacities in refracting media, 87, 

Opaque nerve fibers, 89. 

Opthalmia, chronic, 109, 155, 211, 
218 ; diphtheritic, 124 ; Egyptian, 
109; electric, 415; gonorrheal, 97; 
granular, 107; migratoria, 265; 
military, 107 ; neonatorum, 97 ; 
neuro-paralytic, 471 ; nodosa, 291 ; 
phlyctenular, 133, 155; purulent, 
97 ; strumous, 133. 

Ophthalmitis, sympathetic, 248, 252, 
260, 26y, 288, 289, 372, 393 ; prophy- 
lactic operations in, 278, 415 ; tarsi, 
191. 

Ophthalmometer, 60. 

Ophthalmoplegia, acute hemorrhagic, 
461 ; externa, 460, 463 ; interna, 67, 
460; universa, 460. 

Ophthalmoplegic migraine, 459. 

Ophthalmoscope, 57, 58, 70, 482; 
Helmholtz's, 71 ; modern, 71 ; di- 
rect method. 72 ; indirect method, 

Optic amnesia, 535 ; atrophy, 251, 312, 
355, 405, 413. 414, 433, 435, 438, 439, 
506, 538, 548; axis, 24; center, 24; 
chiasma, 303. 

Optic axis, 18, 484; center, 18, 613. 

Optic disc (or papilla), 34, 46, 75, 
88 ; atrophy of the, 426, 428, 431 ; 
hyaline or colloid outgrowths from 
the, 437; glaucomatous cupping 
the, 89, 322; physiological cupping 
of the, 89, 322. 

Optic ganglia, lesions of the primary^ 

531- 
Optic nerve, 75; atrophy of the, 28, 
501 ; atrophy of the, in tabes dor- 



576 



INDEX. 



salis, 543 ; diseases of, 424 ; in- 
juries of, 437; tumors of, 436. 

Optic neuritis, 89, 251, 265, 271, 424, 
432, 433, 506, 529, 540; retrobulbar, 
432; with persistent dropping 
from nostril, 432. 

Optic radiations. lesions of the, 530^ 
531 ; tract, disease of, 531, 533. 

Orbicular sign, 471. 

Orbicularis palpebrarum, paralysis of 
the, 462. 

Orbit, aneurysm of the, 509; carci- 
noma and sarcoma of the, 508; 
caries of the, 503 ; cellulitis of the, 
501; cysts, hydatid, of the, 507; 
derangement of vision in tumors of 
the, 506 ; diseases of the, 501 ; dis- 
eases of neighboring cavities, 509 ; 
exostosis of the, 508; injuries of 
the, 503 ; lymphadenoma of the, 
508, 509; palpation of the, 505; 
perforating injuries of the, 504] 
periostatis of the, 504 ; shrinking 
of cavity of the, after enucleation 
of eyeball. 513; symmetrical tu- 
mors of the, 509; temporary re- 
section of outer wall of the (Kron- 
lein's operation), 515; tumors of 
the, 426. 

Orbital cysts, 507; cellutis, 493, 501, 

Orbital muscles, ataxy of, 543, co- 
ordinating centers for, 499; re- 
lationship of epilepsy to want of 
power of the, 494; paralysis of. 
502. 538, 543, 637. 

Orbital nerves, paralysis of, 529 ; 
periostitis, 503 ; tissues, edema of, 
505. 

Orbital tumors. 504; diagnosis of 
the nature of, 507. 

Orbital wall, fracture of, 504. 

Orientation, 551. 

Osteoma of the frontal sinus, 510; 
of the sphenoidal antrum, 511. 

Otitis, purulent, 469. 

Ozena, 152, 238. 

Pagenstecher's operation for ptosis, 

200. 
Panas' operation for ptosis, 202. 
Pannus, iii, 121, 129, 518. 
Panophthalmitis, 120, 151. 156, 182, 

248. 263, 268. 371, 384, 632. 
Papillitis, 400, 404, 424; sympathetic, 

274. 



Papilloma of conjunctiva, 128. 

Paracentesis, 258, 411, 412; of cor- 
neal ulcer, 102, 137, 145, 147, 150. 

Parallax, 89. 

Parallax rays, 18. 

Paralysis, acute ascending (Landry's 
disease), 546; agitans, 541; bulbar, 
311, 461, 462; chronic, 462; conju- 
gate lateral, 462; crossed. 470; fas- 
cicular, 463 ; general, of the insane, 
311, 312, 435, 463, 538; infantile, 
633 ; nuclear, 460 ; acute nuclear, 
461 ; chronic nuclear, 461 ; accom- 
modation, 40, 67, 455, 454 ; of cer- 
vical sympathetic, 504; of external 
rectus, 68, 450 ; of the fifth nerve. 
471 ; of fourth nerve, 470 ; of 
levator palpebrae (see Ptosis) ; of 
Miiller's muscle, 504; of orbital 
muscles or nerves, 502, 529, 538, 
543, 551 ; of seventh nerve, 471 ; of 
sixth nerve, 470 ; of sphincter of 
iris, 68, 545 ; of superior oblique, 
451; of third nerve, 68, 454, 466; 
of third nerve, intermittent, of 
one eye, 459; passive orthoptic 
treatment of orbital, 458; rheu- 
matic, 457. 

Paralytic mydriasis, 311; myosis. 309. 

Parasitic disease of the retina, 417. 

Paresis, latent, of an ocular muscle, 
method for discovering, 597. 

Parkinson's disease, 541. 

Pemphigus of the conjunctiva, 122, 
124; vulgaris, 123. 

Pericarditis, 104. 

Perimeter, 30, 446, 483, 484, 548, 552. 

Periostitis, 426. 508, 529; chronic, in 
persons of a rheumatic tendency, 
502; gummatous,, 501 ; of the orbit, 
502, 503 ; syphilitic, 68. 

Peritomy. 117. 

Perivasculitis, 413. 

Petrous portion of temporal bone, 
fracture of apex of, 470. 

Phlegmonous inflammation of the 
eyelids, 187. 

Phlyctenula, 120. 129, 134. 

Phlyctenulas, multiple or miliary, 134. 

Phlyctenular, or strumous conjunc- 
tivitis, or keratitis, 133. 

Phosohenes, 419. 

Photometer, 25. 

Photophobia, 93, 106, 108, 112, 123^ 
134, 135, 139' 540- 



INDEX. 



577 



Photopsia, 550. 

Phtheiriasis ciliorum, 193. 

Phthisis bulbi, 248, 255, 293, 328, 418, 
419, 508. 

Physostigmin (see Eserin). 

Pilocarpin, 309. 318, 337. 

Pineal gland, tumor of the, 469. 

Pinguecula, 126, 127. 

Pituitary body, tumor of the, 529. 

Pleuritis, 104. 

Pneumococcus, 95. 

Pneumonia, 158, 256. 

Poliencephalitis, chronic superior, 
461. 

Poliomyelitis, acute anterior, 461. 

Polycoria, 297. 

Polyopia, monocular, 346. 

Polypi in the sphenoidal antrum, 511. 

Polypus of the conjunctiva, 127. 

Polyuria, 511. 

Pons, disease of the, 470, 471. 

Posterior staphyloma, 46. 

Pregnancy, 411. 

Presbyopia, 64. 

Prisms, 458. 

Progressive muscular atrophy, 311. 

Proptosis, 436, 502, 509, 518, 529; 
paralytic, 505. 

Pseudo-cornea, 170; -glioma, 384, 
417; -leukemia, 509. 

Pterygium, 125, 

Ptosis, 109, 198, 231, 454, 457, 460, 
468; cerebral, 466; congenital, 203^, 
460; monolateral, 467; operations 
for, 200, 201 ; pseudo-, 467 ; sym- 
pathetic, 545 ; with associated 
movements of eyelid, 206. 

Pulvinar, 531, lesion of. 530. 

Punctum lacrimale, malposition of 
the, 233 ; stenosis of the, 233. 

Punctum proximum, 20, 45, 65 ; re- 
motum, 20, 43, 45. 

Pupil, the, 20, 552 ; action of mydria- 
tics on the, 309 : action of myotics 
on the, 309; Argyll Robertson. 
310, 538, 544; artificial, 175, 184^ 
381 ; change of, in accommodation, 
20, 303; contraction of the, 303; 
dilatation of the, 306; exclusion of 
the, 251; hemianopic, the, 532; 
hippus, or unrest, of the, 308; in 
chloroform narcosis, 309; inequality 
of the, 546; malposition of the, 
297; motions of the, in health and 
disease, 303; occlusion of the, 251; 



reflex mobility of the, 305 ; size of 
the. in disease, 309; supernumerary, 
297 ; symptom, paradoxical, 538. 

Pupillary alterations in tabes dorsalis, 
544 ; light reflex, 542 ; membrane, 
persistent, 397; symptoms in mye- 
litis, 546. 

Pyemia, 264. 

QuiNiN amaurosis, 413. 

Railway spine (see Traumatic neu- 
rosis). 

Recti, insufficiency of the internal, 
494. 

Recurrent fever, 256. 

Red vision, 551. 

Refracting surfaces of the eye, 17. 

Refraction and accommodation of 
the eye, abnormal, 36; normal, 17. 

Refraction, estimation of, by ophthal- 
moscope, 76 ; by retinoscopy, 80. 

Regurgitation, aortic, 325. 

Retina, alterations in vascularity of 
the, 400 ; anemia of the, 400 ; aneur- 
ysm of centrf-.l artery of the, 413; 
apoplexy of the, 386, 409, 410, 413^; 
atrophy of the, 403, 407; blinding 
of the, by direct sunlight, 414; by 
electric light, 415 ; cysticercus un- 
der the, 417; detachment of the, 
48, 51, 255, 288, 352, 355, 369, 386, 
395, 397, 404, 410, 418; develop- 
ment of connective tissue in the, 
406; diseases of the, 400; embo- 
lism of the central artery of the, 
410, 434; exudations in the, 400; 
glioma of the, 416; gyrate atrophy 
of the, 409 ; hemorrhages of the, 
400, 406 ; hyperemia of the. 400 ; 
hyperesthesia of the, 553 ; inflam- 
mations of the, 398; injury of the, 
414; ischemia of the, 414; normal, 
89; parasitic disease of the, 417; 
sclerosis of vessels of the, 413; 
spasm of vessels of the, 400; throm- 
bosis of artery of the, 400; throm- 
bosis of vein of the, 400; traumatic 
anesthesia of the, 422 ; traumatic 
edema of the, 422 ; tumor of the, 
416. 

Retinal afifections in diabetes, 405; 
artery, thrombosis of the, 412, 413] 
asthenopia, 477 ; detachment, causes 
of, 419 ; hemorrhages, 541 ; ische- 



578 



INDEX. 



mia, 414; vein, thrombosis of the, 
412 ; vessels, 91 ; vessels, sclerosis 

^t' .413. 
Retinitis, 251, 400, 540; albuminuric, 

400, 402, 403, 424, 555 ; chorioido-, 

401, 434 ; circinata, 406 ; hemor- 
rhagic, 402, 405; leukemic, 405 j 
neuro-, 401 ; ophthalmoscopic ap- 
pearances in, 404 ; pigmentosa, 352, 

406, 407, 434, 554; proliferans, 406; 
punctata albescens, 262, 406; puru- 
lent, 407; specific, 386; syphilitic, 
403, 434; syphilitic chorioido-, 401. 

Retinoscopy, 80; with concave mir- 
ror, 80; with plane mirror, 86. 

Retrobulbar neuritis, 432. 

Rheumatism, 168, 245, 247, 256, 270, 
274, 427, 432, 503, 545- 

Robertson, Argyll, operation for ec- 
tropium, 225. 

Rodent ulcer of the cornea, 190. 

Rods and cones, layer of, 18, 402. 

Rontgen rays, 390; used for diag- 
nosis of retrobulbar growths, 506. 

Saemisch's ulcer, 151. 

Saline injection, subconjunctival, 47, 

153. 

Sarcoma of chorioid, 292; of ciliary 
body, 292; of conjunctiva, 129; of 
eyelid, 197; of iris, 291; of orbit, 
508; of sclerotic, 249. 

Scarlatina, 95, 134, 162, 429, 501, 555. 

Scleritis, 168, 244. 

Sclero-chorioiditis, 381. 

Sclerosis, diffuse, of brain, 537; dis- 
seminated, 313, 428, 434, 462, 463, 
499, 536. 

Sclerotic, diseases of the, 244; in- 
juries of the, 247; pigment spots 
of the, 249; ring, 88; rupture of 
the, 247; tumors of the, 249. 

Sclerotomy, 336, 377; posterior, 333. 

Scopolamin, 309, 316. 

Scorbutus, 555. 

Scotoma, 288, 410, 542; central, 401, 

407, 429, 432, 435, 555; central 
color, 536; paracentric. 430; peri- 
centric, 430 ; peripheral 401 ; posi- 
tive, 261, 386, 414; ring, 401, 408; 
scintillating, 552. 

Scotomata, symmetrical, 552. 
Scott's operation for ectropion, 227. 
Scrofula, 108. 
Septicemia, 256, 407. 



Seventh nerve, paralysis of, 471. 

Shadow test, the, 80 (see Retino- 
scopy). 

Short- sight (see Myopia). 

Shot-silk retina, 89. 

Sideroscope, 354, 392. 

Sight, sense of, 25. 

Sixth nerve, paralysis of the, 470. 

Skin grafts, 513; Thiersch's, 127, 
230; Wolfe and Lefort's, 230. 

Smallpox, 95, 162, 256; conjuncti- 
val complication of, 119. 

Smith, Priestley, method for measur- 
ing strabismus, 482; fusion tubes of, 
487. 

Snellen's operation for ectropion, 
224 ; for entropion, 219 ; sunrise, 55^ 
58, 59; sutures, 224; test-types 
59- 

Snow-blindness, 415. 

Spectacles, after extraction of cat- 
aract, 382 ; in accommodative as- 
thenopia, 41 ; in albinismus, 299 ; 
in anisometropia, 64; in aphakia, 
382; in astigmatism, 57; in conical 
cornea, 174; in convergent strabis- 
mus, 41, 485 ; in cramp of accom- 
modation, 39; in hypermetropia, 
41 ; in incipient cataract, 347 ; in 
irideremia, 298 ; in myopia, 48 ; in 
nebulous cornea, 183 ; in paralysis 
of accommodation, 69 ; in presby- 
opia, 66; numbering of lenses in, 

Sphenoid antrum, exostosis in the, 
511; hyperostosis in the, 511; os- 
teoma in the, 511; polypi in the, 
511; sarcomata in the, 511; tumors 
in the, 511; fracture of the body 
of the, 529. 

Sphenoidal fissure, lesion at the, 447 ; 
periostitis at the, 68. 

Spinal amaurosis, 434. 

Spinal cord, optic atrophy in dis- 
ease of the, 434 : pupil in diseases 
of the, 310; injuries of the, 546. 

Spring catarrh, 105. 

Squint, 472. 

Squinting eye, amblyopia of the, 476. 

Staphyloma, 120, 150, 151. 207, 246. 

Staphyloma, anterior, 398 ; abscission, 
for, 170; evisceration for, 171; 
Mules' operation for, 172. 

Staphyloma, corneal, 148, 182 ; of 
the eyeball, 246; partial, of the 



i 



INDEX. 



579 



cornea, 103, 169; posterior, 46; 
total of cornea, 103, 112, 170. 

Stellwag's sign in exophthalmic goi- 
ter, 518. 

Stenopeic apparatus, 174; spectacles, 
183, 298, 299, 347. 

Stenosis, lacrimal, 93. 

Stereoscope, 479; for treatment of 
strabismus, 486. 

Stomach, hemorrhages from the, 438. 

Strabismus, 446 ; apparent, 446 ; ap- 
parent convergent, 45 ; apparent di- 
vergent, 39. 

Strabismus, alternating, 477, 479; 
concomitant convergent, 41, 471", 
472 ; dangers of operation for^ 
493 ; hypermetropia in, 41 ; meas- 
urement of, 480; by angular meth- 
od, 483; by Hirschberg's method, 
480 ; by linear method, 480 ; by 
method by tangents, 484; mobility 
of eye in, 484 ; monolateral, 476, 
479; operative treatment of, 487; 
orthoptic treatment of, 485 ; peri- 
odic, 474, 479, 485 ; single vision inj 
475 ; stereoscope for treatment of, 
486 ; treatment by spectacles, 485. 

Strabismus, concomitant divergent, 
494 ; absolute, 498 ; dangers of op- 
eration for, 498 ; decentration of 
glasses in, 498. 

Strabismus, paralytic, 472; tangents 
for estimating paralysis of orbital 
muscles, 484. 

Strabometer, 480. 

Strabotomy, 477. 

Streatfield's operation for entropion, 
218. 

Streptothrix in the canalicus, 234. 

Strumous ophthalmia, 133. 

Stye, 193. 

Superior oblique, paralysis of the, 
451. 

Sylvius, aqueduct of, 305, 307. 

Symblepharon, 119, 132, 208, 229. 

Sympathectomy, $37. 

Sympathetic irritation, 265, 554. 

Sympathetic ophthalmitis, 248, 252, 
260, 266, 288, 289, 372, 393. 

Synchysis, 386; scintillans, 387. 

Synechia, anterior, 103, 147; circu- 
lar, 251; complete, 251, 339; pos- 
terior, 251, 255, 305, 339; ring, 251, 
339. 

Syphilis, 68, 108, 168, 235, 270, 274; 



427, 457, 470, 539, 545; congenital. 
164, 247, 256, 264, 413; of con- 
junctiva, 128; primary, 189; sec- 
ondarv. 190, 403, 502; tertiary, 190. 

Syphilitic chorioido-retinitis, 401 ; 
iritis, 253, 254, 259; sores of the 
eyelids, 189. 

Syphiloma, 425. 

Syringomyelia, 546. 

Tabes dorsalis, 311, 312, 428, 434, 

543- 

Tenia solium, 417. 

Tarsal tumor, 194. 

Tarsorrhaphy, 207, 224, 521. 

Tarsus, no. 

Tattooing for leukoma of cornea, 177, 
184. 

Teale's operation for symblepharon,, 
209. 

Teeth, disease of the, 501, 553. 

Teleangiectic tumors of the eyelids, 
195, 509. 

Temporo-sphenoidal lobe, tumor of 
the, 533- 

Tenotomy for strabismus, 459, 481, 
488, 489. 

Tension of the eyeball, high or glau- 
comatous, 52, 182, 321 ; normal, 321. 

Test-types, 29. 

Thermo-cautere, 145, 176. 

Third nerve, paralysis of, 68, 454, 
459, 466. 

Thomson's disease, 546. 

Thrombosis, cerebral, 527; of retinal 
vessels, 412. 

Tonometers, 321. 

Toxic amblyopia, 28, 429; paralvsis, 
68. 

Trachoma (or granular ophthalmia), 
107, 121, 122, I2A, 356; acute, 108; 
chronic, no; forceps for treat- 
ment of, 115. 

Trial lenses, numbering of, 17. 

Trichiasis, in, 192, 211. 

Tropa-cocain, 319. 

Trousseau's cerebral macula, 519. 

Tubercle of the brain, 425, 529, 533; 
of the chorioid, 294 ; of the con- 
junctiva, 121 ; of the iris, 289. 

Tubercular meningitis, 425, 632. 

Tuberculosis, attenuated, of the iris, 
290. 

Tumor, cerebral, 425 ; intracranial, 
312, 511; intra-ocular, 312, 340, 



58o 



INDEX. 



352, 398; in the antrum of High- 
more, 511 ; in the antrum of the 
sphenoid, 511; in the body of 
the sphenoid bone, 511; in the 
ethmoid cells, 510; in the frontal 
sinus, 510; in the maxillary 
antrum, 511; of the lacrimal gland 
512; of the lenticular nucleus, 
533; of the optic nerve, 436; of 
the optic thalamus, 523; of the 
pituitary body, 511, 529; of the 
temporo-sphenoidal lobe, 533- 
Typhoid fever, 158, 256, 429, 50i. 

Ulcer of the cornea, absorption, 155; 

deep, 150; faceted, 155; rodent, 

153; in purulent conjunctivitis, 98; 

ring, 135- 154; serpiginous, 151; 

simple, 149; superficial transparent, 

156, 
Uremia, 404. 
Uric acid deposits in the conjunctiva, 

131^ 

Uterine hemorrhage, 437. 
Uveal tract, diseases of the, 250. 
Uveitis, plastic, 354, Z7^, 393; puru- 
lent, 393. 

Vaccine, vesicles, 190. 

Valve of Vieussens, lesion of, 470. 

Van Millingen's operation for trichi- 
asis, 217. 

Vertigo, 550. 

Vienna operation for enucleation, 
278. 

Vision, acuteness of, 28, Z'2', 52; bi- 
nocular field of, 32; central, 30, 
401 ; center of, lesion at the, 522 ; 
color, 434; contraction of field of. 
125 ; direct, 30 ; eccentric, 30 ; field 
of, 30, 324, 356; indirect, 30; mo- 



nocular, double, 381 ; nulle, 530, 
531- 

Visual angle, 29; aphasia, 534; axis, 
484; center, situation of, 524; hal- 
lucinations, 535, 550; line, 22, 24; 
memory, 535, 536. 

Vitreous humor, 17, 51 ; artificial. 
172; blood-vessels in the, 397; 
cholesterin in the, 2)Z7 ; cysticer- 
cus in the, 396; detachment of the 
from the retina, 397; diseases of 
the, 384; fluidity of the, 386; for- 
eign bodies in the, 386; hemor- 
rhages into the. 386, 398, 405, 406; 
inflammatory affections of the, 384; 
opacities in the, 47, 120, 246, 251. 
260, 384, 385, 417, 418; persistent 
hyaloid artery in the, 397; prolapse 
of the, 362, 368; purulent inflam- 
mation of the, 384. 

Vossius' operation for trichiasis, 216. 

de Wecker's operation for staphy- 
loma of the cornea, 170. 

Wernicke's pupil-symptom, 532. 

Wharton-Jones' operation for cica- 
tricial ectropion, 228. 

Whooping-cough, 127, 158, 264, 478. 

Wolff's operation for congenital 
ptosis, 205. 

Word-blindness, 531, 533. 

Xanthelasma of the eyelids, 195. 

Xerophthalmos, or xerosis of the 

conjunctiva, 119, 123, 208, 512, 554. 

Yellow oxid of mercury ointment, 

137. 

Young-Helmholtz theory of the 
color-sense, 25. 

Zonular cataract, 350. 



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BtTBJECT. PAGE 

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Anatomy 7 

Anesthetics _ 18, 19 

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Bandaging (see Surgery) . . 24 

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MEDICAL BOOKS. 19 

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RICHARDSON. Long Life and How to Reach It. .40 

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TISSIER. Pneumotherapy, Aerotherapy, Inhalation Methods. 

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WEBER AND HINSDALE. Climatology and Health Resorts. 
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WILSON. The Summer and Its Diseases. .40 

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logic TherapeiUics, page 17. 

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DERCUM. Rest, Suggestion, Mental Therapeutics. See Cohen, 
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NURSING (see also Massage). 

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PATHOLOGY. 

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MEDICAL BOOKS. 21 



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MEDICAL BOOKS. 23 



GOULD AND PYLE. Cyclopedia of Practical Medicine and 
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MEDICAL BOOKS. 25 

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THROAT. Illustrated. 

27 



DA COSTA 



Clinical Hematology 



A Practical Guide to the Examination of the Blood by 
Clinical Methods. With Reference to the Diagnosis of 
Disease. With Colored Illustrations. Cloth, $5.00 

*^* A new, thorough, systematic, and comprehensive 
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research, but to supply a book for the student, the hospital 
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wanting in none of these respects. 

OERTEL 



Medical Microscopy 

JUST READY 

A GUIDE TO DIAGNOSIS, ELEMEN- 
TARY LABORATORY METHODS, 
AND MICROSCOPIC TECHNtC 

By T. E. Oertel, M.D., 

professor of Pathology and Clinical Microscopy, Medical Depart- 
ment, University of Georgia. 

WITH 131ILLUSTRATIONS. lamo. Cloth, $2.00 

28 



The Pocket CyclopediaL of 
Medicine and Surgery 

Full Limp Leather, Round Corners, Gilt Edges, $1.00 
With Thumb Index, $U5 

Uniform 'with '^ Gould's Pocket Dictionary " 



A concise practical volume of nearly 600 
pages, containing a vast amount of infor- 
mation on all medical subjects, including 
Diagnosis and Treatment of Disease, 
witH Formulas and Prescriptions, Emer- 
gencies, Poisons, Drugs and Tticir Uses, 
Nursing, Surgical Procedures, Dose List 
in both English and Metric Systems, etc* 

By Drs. Gould and Pyle 

Based upon their large ** Cyclopedia of 
Medicine and Surgery/' ^ S ^ 



*^* This is a new book which will prove of the greatest 
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in shape for quick reference. In no other book can be 
found so much exact detailed knowledge so conveniently 
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It is Multum in Parvo. Sample Pages Free. 
29 



A NEW EDITION 



Crocker on the Skin 



The Diseases of the Skin. Their Description, Pathology, 
Diagnosis, and Treatment, with Special Reference to the 
Skin Eruptions of Children. By H. Radcliffe Crocker, 
M.D., Physician to the Department of Skin Diseases, Uni- 
versity College Hospital, London. With new Illustrations. 

Third Edition, Rewritten and Enlars^ed 

OCTAVO. JUST READY ; CLOTH, $5.00 

*^* This new edition will easily hold the high position 
given the previous printings. The author is a member of 
American, English, French, German, and Italian Dermato- 
logical Societies, and a recognized authority the world over. 



STURGiS— MANUAL OF 
VENEREAL DISEASES 



By F. R. Sturgis, m.d., Sometime Clinical Professor of 
Venereal Diseases in the Medical Department of the Uni- 
versity of the City of New York. Seventh Edition, Revised 
and in Part Rewritten by the Author and Follen Cabot, 
M.D., Instructor in Genito-Urinary and Venereal Diseases 
in the Cornell University Medical College. i2mo. 216 
pages. Cloth, $1.25 

*.^* This manual was originally written for students' 
use, and is as concise and as practical as possible. It pre- 
sents a careful, condensed description of the commoner 
forms of venereal diseases which occur in the practice of 
the general physician, together with the most approved 
remedies. 

30 



FOR THE DISSECTING ROOM 

Holden*s Anatomy — Seventh Edition 
320 Illustrations 

A Manual of the Dissections of the Human Body. By John 
Langton, F.R.c.s. Carefully Revised by A. Hewson,m.d., 
Demonstrator of Anatomy, Jefferson ISIedical College, Phila- 
delphia, etc. 320 Illustrations. Two small compact vol- 
umes. i2mo. 

Vol. I. Scalp, Face, Orbit, Neck, Throat, Thorax, Upper 
Extremity. 435 pages. 153 Illustrations. 

Oil Cloth, $1.50 
Vol. II. Abdomen, Perineum, Lower Extremity, Brain, 
Eye, Ear, jNIammary Gland, Scrotum, Testes. 
445 pages. 167 Illustrations. 

Oil Cloth, $1.50 
Each volume sold separately. 



Hughes a^nd Keith — Dissections 
lUustrdLted 

A Manual of Dissections by Alfred W. Hughes, m.b., 
M.R.C.s. (Edin. ), late Professor of Anatomy and Dean of 
Medical Faculty, King's College, London, etc., and Arthur 
Keith, m.d.. Joint Lecturer on Anatomy, London Hospital 
Medical College, etc. In three parts. With 527 Colored 
and other Illustrations. 

I. Upper and Lower Extremity. 2)^ Plates, 1 16 other 
Illustrations. Cloth, $3.00 

II. Abdomen. Thorax. 4 Plates, 149 other Illus- 
trations. Cloth, ^3.00 
III. Head, Neck, and Central Nervous System. 16 
Plates, 204 other Illustrations. Cloth, $3.00 

Each volume sold separately. 

*^* The student will find it of great advantage to have 
a "Dissector" to supplement his regular text-book on 
anatomy. These books meet all requirements, and as they 
can be purchased in parts as wanted, the outlay is small. 
31 



EDGAR'S 

OBSTETRICS 

A NEW TEXT -BOOK 
I 22 1 Illustrations 



Edgar's Obstetrics excels all 
other works on this subject 
in completeness, in uni- 
formity and consistency in 
arrangement, thoroughness 
and clearness in handling 
details, and in the number 
and usefulness of its illus- 
trations. 

OCTAVO. CLOTH, #6.005 SHEEP, #7.00 



CARD EXPLANATORY OF HOLMGREN'S TESTS 
FOR COLOUR BLINDNESS. 

Test L 



Confusion Colours. 



1 z 

I I 



I 



u 



Test II. a. 



Confusion Colours. 
Red Blindness. 



Confusion Colours. 
Green Blindness. 



I I 




Test II. b. 



Confusion Colours. 
Red Blindness. 



Confusion Colours. 
Green Blindness. 



10 



11 



12 



18 



M 



I I 



N.B. — This Card is merely intended to ilkistvate the text (The 
Colour Sense, Chap. I. and Appendix I.), and is not itself for 
use as a test. 



